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1
HEALTHY MOTHER HEALTHY CHILD
INTERSECTORAL NUTRITION STRATEGY FOR GB
2016-2020
2
GB – INTERSECTORAL NUTRITIONAL STRATEGY
List of acronyms…………………………………………………………………………………...3
Introduction............................................................................................................... .........4
Rationale for integrated approach to addressing malnutrition.............................................5
Objectives of the inter-sectoral nutrition intervention..........................................................6
Target Groups.....................................................................................................................7
The Guiding Principles........................................................................................................7
Underlying assumptions......................................................................................................10
Desired Result outcomes of the inter-sectoral nutrition intervention...................................10
Oversight Coordination Monitoring and Evaluation.............................................................13
Approval of inter-sectoral nutrition plan...............................................................................14
Result monitoring framework...............................................................................................14
Sectoral Interventions....................................................................................................... 15
Department of health and population welfare.......................................................................16
Department of agriculture/food/livestock/poultry and fisheries ............................................24
Department of water and sanitation......................................................................................30
Department of education sector........................................................................................... 33
CROSS CUTTING SECTOR.............................................................................................38
Cross sector one: women development department – (WDD)..........................................39
Cross sector two: social protection and poverty alleviation...............................................46
Cross sector three: NGO/civil society private sector in INSGB ........................................49
Annexure ..........................................................................................................................53
3
LIST OF ACRONYMS ADP Annual Development Program BCC Behaviour Change Communication BISP Benazir Income Support Program BHU Basic Health Unit BPCR Birth Preparedness and Complication Readiness CBA Child Bearing Age CSO Civil Society Organization CMAM Community-based Management of Acute Malnutrition CMWs Community Mid wifes DHIS District Health Information System DOH Department of Health EPI Expanded Program on Immunization FWW Family Welfare Worker GB Gilgit Baltistan GDP Gross Domestic Product IDA Iron Deficiency Anemia IMR Infant Mortality Rate INSGB Intersectoral nutrition strategy for GB IYCF Infant and Young Child Feeding LBW Low Birth Weight LHW Lady Health Worker M&E Monitoring and Evaluation MI Micronutrient Initiative MNCH Maternal, Neonatal and Child Health MOU Memorandum Of Understanding NGO Non Governmental Organization NIDs National Immunization Days NNS National Nutrition Survey NPS Nutrition Program for Sind NWFFP National Wheat Flour Fortification Project PC-1 Planning Commission-proforma 1 PDHS Pakistan Demographic and Health Survey PHC Primary Health Care PLW Pregnant and Lactating Women PSLSM Pakistan Social and Living Standards Measurement PWD Population Welfare Department RUTF Ready to Use Therapeutic Food SAM Severely Acute Malnutrition TORs Terms of References
4
1.0. INTRODUCTION
Pakistan reports a very high under 5 mortality rate with Pneumonia, Diarrhea and measles- as
the major killers and under-nutrition as an underlying risk factor 1 . According to UNICEF’s
report2, severely underweight children are 9.5 times more likely to die of diarrhea than a child
who is not; stunted children are 4.6. times more vulnerable to die in this age group.
Punjab
Sindh KPK Baluchistan FATA AJK GB
Stunting
Mild to
severe
65.6 72.4 66.9 76 78.7 61.7 75.1
Wasting
Mild to
severe
37.1 46.3 30.1 34.5 16.3 41.5 19.5
Underweight
Mild to
severe
61.7 71.2 47.6 64.4* 25.3 59.9 59
In comparison to the national averages, the National Nutrition survey (NNS 2011) indicates that
Gilgit-Baltistan (GB) has comparatively high prevalence of stunting 75.1 %3 when compared to
other provinces except Baluchistan. Prevalence of mild to severe wasting is 19.54% which is
lower than the other regions. On the other hand, prevalence of underweight is also high (59%).
The situation is worse in the rural areas. In addition, anemia in children of less than five years of
age in GB is 41%5 and iron deficiency anemia is 36.2%6 in the same age group. Micronutrient
deficiency in children of less than five years of age from GB is also very high (71.8%)7 and vit. D
deficiency is 37% 8
The NNS 2011-12 also highlights poor nutritional status of mothers in GB indicated by 33%9 of
pregnant women and 23.3% of non pregnant women reporting anemia. 17.110% of women in
1 Improving child nutrition-The acheiveable imperative for global progress. UNICEF, April 2013 2 Ibid 3 INS 2011 new –pag table 6.3. 4 4 INNS PPT gilgit Dec - slide 45 5 NNS 2011, new version, fig 6.10 6 NNS 2011, new version, fig 6.12 7 NNS 2011, new version, fig 6.13 8 NNS 2011, new version, fig 6.17 9 NNS 2011, new version, fig 5.10 10 NNS 2011 pg. 98
5
14-49 years and 14.6% of non pregnant women11 in the survey were found to be malnourished
(BMI<18.5). Similarly prevalence of micro nutrient deficiency was also reported to be high in
women in NNS 2011. 39.1%12 of pregnant women reported moderate to severe vit A deficiency
and almost similar prevalence of Vit. A deficiency was found in non pregnant women13. GB also
reports a very high prevalence of Vit. D deficiency (80.5%) amongst pregnant women14. The
survey assessed calcium levels in the serum of the pregnant women and reported hypo-
calcemia to be as high as 46.7%15
There are gains in reducing iodine deficiency in Gilgit-Baltistan, but anemia and other
deficiencies including vitamin A remained unchanged since the last survey of 2001. NNS 2011
has highlighted that 84.9% 16 samples collected from the market had iodine content of ppm >15
ppm. Similarly reported use of iodized salt is as 95% and use awareness about benefits of
iodized salt amongst mother is excellent i.e. 79.5%17.
2.0. RATIONALE FOR INTEGERATED APPROACH TO ADDRESSING
MALNUTRITION
NNS 2011 has highlighted malnutrition in GB is a major problem (annexure 1). The UNICEF
framework clearly highlights that causes of malnutrition are multiple in nature ranging from
immediate causes, underlying causes and the basic causes (Annexure 2). These causes can be
addressed with two types of interventions: Nutrition specific intervention and Nutrition sensitive
intervention
The nutrition specific interventions are more specific to the health sector. Traditionally, these
interventions have been implemented to address the issue of malnutrition. These interventions
are health specific and require presence of a functional health system with trained and
dedicated staff and adequate logistic support. Nutrition specific interventions for the prevention
and treatment of stunting and other forms of under-nutrition are given in annexure three:18
11 Ibid 12 NNS 2011 new version fig 5.24 and 5.25 13 NNS 2011, new version, fig 5.30. 14 NNS 2011, new version, fig 5.17 15 NNS 2011, new version, fig 5.18 16 NNS 2011, new version, section 5.3.3
17 NNS 2011, new version, section 5.3.3 18Scaling Up Nutrition: What Will it Cost? Horton, et.al. 2009
6
Nutrition sensitive interventions are broader in nature and address the underlying and basic
causes of malnutrition. These interventions include income generation at household level,
diversity of production and consumption, actions to enhance social status of women, special
assistance to marginalized population to ensure availability and affordability for food items such
as through provision of food vouchers, incentivising girl child education and ensuring access to
safe water and sanitation.
Analysis of sectoral strategies in GB indicates that various sectors are already implementing or
envisaging implementation of nutrition sensitive strategies in their own demarcated thematic
areas .
According to Lancet 2013, “nutrition sensitive interventions also enhance the scale and
effectiveness of nutrition-specific interventions”. The strategy rests on the principle that the
co-location or convergence of nutrition specific and nutrition-sensitive interventions in the same
vulnerable geographic areas permits synergistic benefits and is capable of producing significant
reductions in stunting (over 4 percentage points a year in Peru and parts of Bangladesh).
There is however a need for more coherent multi sectoral interventions in prioritized areas to
reach out to marginalized segment of the population. This is however, only, possible when
various sectors plan together a coordinated and coherent inter-sectoral intervention.
3.0. OBJECTIVES OF THE GILGIT BALTISTAN INTER-SECTORAL
NUTRITION STRATEGY
The overall objective of the inter-sectoral nutrition strategy is to provide guidance to the relevant
sectors in reducing the burden of chronic malnutrition in GB through sustainable, effective and
inter-sectoral interventions. The strategy seeks to reduce:
Prevalence of underweight children aged 6 to 59 months by 10 percentage points (from
an estimated 5919% to 49% by the end of 2020)
Prevalence of anemia in under 5 year old20 children rom 41% to 31% by the end of 2020
Anemia in pregnant women from 33% to 23%% by the end of 2020.
Prevalence of anemia in non pregnant women21 to decrease from 23% to 15%.
19 NNS new Table 6.3 20 NNS 2011 new page 38 21 NNS 2011 new version table 5.19
7
4.0. TARGET GROUPS
4.1. Minus nine months to two years (Preconception, conception, pregnancy
and lactating women and early childhood)
Scientific evidence indicates that first 1,000 days after conception is the most critical period of
child development. A mother who is malnourished during pre-pregnancy or who receives
inadequate food and care during pregnancy is at high risk of developing a low-birth weight
infant, who, in turn, will have a decreased likelihood of survival. 22 Combined early child
development and nutrition activities show promising, additive and synergistic effects on child
development. Although, this age group is already being targeted through CMW, LHW, FWW
and community outreach programs, investments will be increased, streamlined, and further
targeted with special attention given to BCC through intensive inter personal counselling and
mass media, radio and television.
4.2. Adolescents
Inter-sectoral strategy gives priority focus to adolescent girls. Reaching adolescent girls is
important given the critical importance of pre-pregnancy nutritional status in reducing low birth
weight in babies. Eating nutritious diet and administration of weekly iron tablets has potential to
increase iron stores. Adolescent boys need to be reached as future facilitators of gender equity,
underlining also the important male role in child care.
5.0. THE GUIDING PRINCIPLES
5.1. Principle one: Recognition of right to food
The right to food is the first fundamental principle underlying this strategy. It is defined as:
"The right to have regular, permanent and unrestricted access, either directly or by financial
purchases, to quantitatively and qualitatively adequate and sufficient food corresponding to the
cultural traditions among the people to which the consumer belongs, and, which ensure a
physical and mental, individual and collective, fulfilling and dignified life free of fear."
The definition has two underlying concepts23:
22 Scaling Up Nutrition: The UK’s position paper on undernutrition, September 2011 23http://en.wikipedia.org/wiki/Right_to_food#CITEREFCommittee_on_Economic.2C_Social_and_Cultural_Rights 1999
8
Right to adequate food: This implies not only the absence of malnutrition, but also
access to a variety of food, food safety and dignity,
The "fundamental right to be free from hunger": This can be measured by the
number of people suffering from malnutrition and at the extreme, dying of starvation.
Principle two: Evidence-based interventions
Nutrition interventions instituted globally with well designed policies, and interventions have
shown remarkable reduction in the rates of under-nutrition. In designing a strategy for GB,
international evidence has been studied with interventions that has impact on women and
children health.
Principle three: Geographical convergence
The strategy proposes equity in institution of the nutrition intervention. It is proposed that
malnutrition prevention and management is prioritized in the most high-risk areas identified in
the NNS 2011. Even within districts, there are UCs which are more deprived than others. The
strategy will focus on the interventions at the district level, and, within districts, in high-risk UCs.
It is proposed that all sectors reach agreement on priority districts to ensure coherent
implementation of a convergent approach.
Principle four: Gender empowerment
The status of women is strongly associated with nutritional outcomes. A strong association
exists to indicate a robust association between women’s education/literacy and nutritional
status. One study24 found that improving women’s status in South Asia would reduce the level
of underweight young children by approximately 12%. Another study found that giving 1000 girls
one additional year of primary education would prevent roughly 60 infant deaths and three
maternal deaths, while averting some 500 births25.
Principle five: Inter-sectoral interventions
The role of other sectors, in addition to the health sector, in improving the nutritional status of
the population is crucial. These multiple sectors through their coordinated interventions can
reduce vulnerability to illness and can play a vital role in healthy behavior development. Analysis
24 L. Smith, U. Ramakrishnan,A. Ndiaye, L. Haddad, and R. Martorell, The Importance of Women’s Status for Child Nutrition in Developing Countries,Research Report 131, IFPRI, 2003 25 www-wds.worldbank.org/servlet/WDSContentServer/WDSP/IB/.../multi_page.pdf
9
of basic and underlying causes of under-nutrition makes clear that interventions to address
them must be inter-sectoral in nature.
Principle six: Multi-sectoral planning, sectoral implementation and inter-sectoral review
Mechanisms will be established to generate effective coordination for joint planning and review
across sectors. Efforts will be made to circumvent traditional stumbling blocks expected in such
efforts, among them (a) fears of jeopardizing sectoral integrity, (b) sectoral competition, and (c)
fear of dominance by a single sector – in this case health. At the same time, the strategy
recognizes that implementation of nutrition specific and sensitive activities are best carried out
sectorally.
Principle seven: Encourage involvement of the civil society
The strategy envisions a critical and constructive role of the civil society. It is proposed that
instead of a symbolic participation, civil-society stakeholders are encouraged to actively
participate in governance, planning and in implementation, particularly in matters relating to
behavior change, social marketing, research, monitoring and advocacy. The strategy will
provide opportunities to civil society for public-private partnerships that place high premiums on
innovation and on access to affordable services. The strategy will solicit inputs from civil society
through consultation and policy dialogue.
Principle eight: Common targets and indicators
The strategy acknowledges that while inter-sectoral action is capable of producing major effects
on nutritional outcomes (e.g. stunting), not all sectors are likely to be able to affect such
indicators on their own. Hence, agriculture projects may improve household food security of
formerly insecure households; it will make a major contribution to improved nutrition when
coupled with interventions from other sectors. Similarly, education projects which increase
female school enrolment and attendance or improve female literacy will also have its significant
impact upon the nutrition outcome indicator. Comparable reporting formats across sectors
involving local, district and provincial review holds promise to enhance intersectoral nutrition
intervention implementation. The data use for evidence based decision making will also be
encouraged as well as ensuring collection of validated data.
10
6.0. UNDERLYING ASSUMPTIONS
i. There is a commitment to rapidly scale up both domestic and external investment for
inter-sectoral nutrition interventions;
ii. Development partners will harmonize their external assistance, will seek to reduce
fragmentation and to enhance mutual accountability;
iii. Government is ready to embrace public-private partnerships for enhancing agriculture
and crop productivity and other sector’s upliftment
iv. Government, and non-governmental sectors and elected representatives assume
ownership of the strategy;
v. There is acceptance of the concept of one integrated provincial and district level
monitoring and evaluation system;
vi. Nutrition sensitive programs will help scale up nutrition specific intervention.
vii. Key sectors, i.e. health, agriculture, food/ livestock/poultry and water and sanitation are
committed to coordinating and collaborating intersectorally and cross sectorally and
ensure that their interventions are pro-poor, gender and nutrition supportive.
7.0. DESIRED RESULT /OUTCOMES OF GB INTERSECTORAL NUTRITION
STRATEGY INTERVENTIONS INS GB has proposed actions that will enable the region to achieve its desired aspiration to
improve the nutrition outcomes of the population through nutrition sensitive and nutrition specific
interventions. In the next 5 years, these results will be measured through clear indicators
included in the annual work plans. Achieving these results outcomes would enable the province
to embrace other developmental interventions that will not only prevent mortality and morbidity
amongst women and children but will also improve their productivity leading to a better quality of
life. It should be noted that in the section of inputs, most of the activities get initiated in 2016
based on the assumption that the INSGB will be approved in 2015. Outputs of intersectoral
strategy are given in annexure four. In the later section, outcomes for each of the sectors have
been documented; this section refers to overarching outcomes of the INS-GB.
11
Intermediate outcome 1: All sectors have adopted a common vision and strategic
direction for reducing malnutrition
Outputs:
i. All nutrition sectoral strategies developed are nutrition sensitive and formulated after
review of the existing sectoral strategy
ii. Enhanced provincial capacity for stewarding and formulating evidence-based policies .
iii. Individuals and communities are informed about the benefits of good nutrition for young
adolescent girls and children and will change their attitudes towards family practices;
iv. Incentives introduced for increasing demand and access to healthy and fortified food.
v. Various sectors participated in advocacy for healthy food and nutrition.
Intermediate outcome 2: Food security and safety enhanced equitably across entire
Gilgit Baltistan with emphasis on reaching out to underserved areas
Outputs:
i. Marginalized and underserved areas received prioritized nutrition specific and nutrition
sensitive interventions
ii. The food available in the market is certified by accredited authority for its quality and
safety
iii. Households have adopted the practice of consuming fortified food and use of iodized
salt
iv. Farmers, livestock producers and fisheries are using modern and safe methods to
improve their produce.
v. Private sector have successfully launched initiatives that enhance production of bio-
diverse food at affordable price
Intermediate outcomes 3: Access to health, nutrition and developmental opportunities to
women and children is optimized
Outputs
a) Schools are offering nutrition and life skill education to children as part of their curriculum
12
b) Adolescent girls are receiving weekly iron supplements from their schools
c) Gender sensitive social protection packages have enhanced economic empowerment of the
women in the population
d) Household income and food diversity increased as a result of vegetables and fruits grown in
the kitchen garden
Intermediate outcomes 4: Access to safe water and sanitation facilities enhanced in the
marginalized population and areas
a) Increased %age of households in geographically deprived areas have access to clean/safe
piped or tube well / boring water
b) Increased %age of households have access to safe sanitation facilities
c) Increased %age of population is using soap for hand-washing.
d) WASH sector has instituted gender sensitive WASH interventions by adopting inclusive
process that ensures women participation in the designing and follow-up of all WASH
schemes.
e) Schools have ensured availability of clean/safe water and sanitation facilities for children
Intermediate outcomes 5: Nutrition sensitive incentives in the social protection package
has reduced poverty and increased agricultural output
Output
a) Benazir Income Support Programme (BISP) has introduced schemes that incentivizes
parents to send their daughters to school
b) BISP has expanded its vocational training package to enable women to acquire skills and
increase their incomes.
c) BISP has offered loans that has enabled small farmers to increase their produce through
purchasing agricultural inputs in a timely manner
Intermediate outcomes 6: Increased numbers of women and children have access to
health specific intervention
Outputs
a) Increased % of infants from 0-6 months of age are breast fed within 1st hour of birth
13
b) Increase % of infants aged 6-12 months of age who received exclusive breastfeeding up to
six months of age
c) Increased % of children aged 12-24 months introduced to complementary food between 6-8
months of age
d) Increased % of mothers with a child aged 0-12 months received any ANC during their last
pregnancy
e) Increased % of mothers with a child aged 0-24 months who received any micronutrient
supplements during her last pregnancy
f) Increased % of children aged 12-60 months who received vitamin A supplement in the past
6 months
g) Increased % of children aged 6-24 months who consumed multi-micronutrient powder for
atleast two months every six monthly period
8.0. OVERSIGHT COORDINATION MONITORING AND EVALUATION
Province based oversight inter-sectoral nutrition program committee
The strategy proposes establishing a province based inter-sectoral committee which will be instrumental
in planning nutrition-specific and nutrition-sensitive programs, harmonizing information dissemination and
reviewing program results. The committee will have the authority to track district annual implementation,
address bottlenecks and limiting factors quickly and efficiently, and ensure accountability for results.The
secretariat of the inter-sectoral strategy implementation will be based in the P&D Department. It is
proposed that under the chairmanship of P&D department, following departments will represent on the
committee.
Departments of Agriculture, Food, Livestock and Fisheries
Department of Education (DoE)
Departments of Health (DoH) and Population Welfare
Departments of Public Health Engineering (PHED) and Local Government
Departments of Women Development (WDD) and Social Welfare
Department of Finance
The committee will also have representation of the civil society. The ToR of the committee is attached as
Annexure 5.
14
9.0. APPROVAL OF INTERSECTORAL NUTRITION PLAN
– An inter-sectoral nutrition cell is proposed in the P and D in the province, to provide guidance,
support, coordination and processing of nutrition sensitive intervention across all the sectors.
– Inter-sectoral strategy will be the central tool to provide direction and monitoring indicators to see
progress on the nutrition status
– Concerned departments will make their plans which are nutrition sensitive preferably
using the Nutrition Strategy
– Concerned department will also review their existing plans in pipeline and will aim to
make these nutrition sensitive
– P & D will ensure that plans submitted for funding are nutrition sensitive
– Plans will be funded either by ADP or foreign assistance.
10.0. RESULT MONITORING FRAMEWORK
The log frame below (Annexure 6) lays out GB’s nutrition strategy schematically.The annexure presents
matrices of the actions to be taken by each involved sector with timelines, responsible entities, and, in
some cases, expected impact. Targets for various results have been agreed with the subsectors through
the Inter-sectoral Nutrition Technical Working Group.
15
SECTORAL INTERVENTIONS
16
DEPARTMENT OF HEALTH AND POPULATION WELFARE
SUMMARY OF HEALTH SPECIFIC RECOMMENDATIONS
Action Area 1: Enabling environment, policy frameworks, strategies
Recommendation 1.1: Develop a comprehensive provincial specific health and nutrition policy
Recommendation 1.2: Establish an oversight intra-sectoral coordination group to harmonize various sub sectors of health aimed at reducing fragmentation in health service delivery.
Recommendation 1.3: Enforce legislation on the “Protection of Breast-Feeding and Child Nutrition Ordnance” from all private and public sector facilities
Action Area 2: Capacity Development and Coordination
Recommendation 2.1: Parents and school teachers and other outreach workers will be trained to play a key role in creating awareness about early identification and treatment of malnourished children.
Recommendation 2.2: Develop knowledge and competency of the health care providers and establish system for effective prevention of malnutrition
Recommendation 2.3: Nutrition cell in health sector will strengthen the curriculum of the health outreach workers in the area of nutrition promotion and will organize a capacity building plan that builds the capacity of 100% of the workers over the next three years
Action Area 3: Field Based Implementation
Recommendation 3.1: Revive and strengthen LHW/PHC program to enable them to play an active role in the early identification, prevention of malnutrition and promotion of health
Recommendation 3.2: Health department will facilitate establishment of formal linkages between LHW-PHC program and Education sector to ensure more than 95% of the school children receive at least once a year screening and twice a year deworming.
Recommendation 3.3: Increased emphasis would be laid on preventing malnutrition among expectant mothers and her baby through strengthening counselling, care and support from various primary and community-based clinics and programs.
Recommendation 3.4: Strengthen nutrition cell or cell? to ensure that the nutrition related activities are implemented and monitored in an efficient manner
Recommendation 3.5: Reporting system needs to be strengthened to monitor the coverage of Vitamin A capsule administration to children through diet.
Action area 4: Research and development
Recommendation 4.1: Undertake research to identify underlying reasons for malnutrition in GB context;
17
RESULT FRAMEWORK FOR HEALTH AND POPULATION SECTOR
outcome 1 NNS 2011 Indicator 2018
Indicator 2020
MoV
Child stunting (H/A <2)26 50.6% 35% 30% Semi-annually HMIS
Output 1.1: . Evidence based and gender-sensitive health and nutrition policy will be enforced in GB.
Activities
Means of verification Timeline Sectors Budget
The policy dialogue held with the stakeholders to define the scope of nutrition policy;
Approved Nutrition Policy
document
May 2016
DoH, Stakehlders
Lobbyist, CSOs
Needed
Output 1.2:. Establish an oversight intra-sectoral coordination group to harmonize various sub sectors of health aimed at delivery of 1000 days healthy
mother and baby program.
Activities Means of verification
Timeline Sectors
Intrasectoral nutrition platform commissioned to play a leadership role in the development of the complementary initiatives through mobilizing the subsectors around nutrition
Notification of intra-sectoral oversight nutrition platform
Jan 2016 DoH-sub sector, Nutrition cell
Proposal is submitted to Pand D for strengthening the capacity of the nutrition cell and to enable it to play a catalytic role in the implementation of the intersectoral nutrition strategy
Approved proposal and budget allocation
March 2016 Pand D, DoH
Include nutrition specific indicators in DHIS along with mechanism for reporting from various sub sectors of health.
DHIS report with nutrition specific indicators
June 2016 DoH-sub sectors Nutrition cell MIS department
All the sub sectors of health will report to the oversight committee on the progress of various milestones identified in
Quarterly report for the oversight committee
2016 March onwards
DoH-sub sectors Oversight group
26 PINS and operational plan presentation – slide 2
18
the INS along with reporting on monitoring and evaluation when ready and institutionalized
BCC strategy developed with key nutritional messages to be disseminated from various platforms for behavior change and re-enforcement
List of key nutritional messages March 2016 DoH focal person Nutrition focal person BCC specialist
Continuity of care ensured and missed opportunities reduced for identification and treatment of malnourished children through building functional linkages between various levels of health service delivery
MoU between nutrition cell and LHW, FWW, MNCH and EPI program for identification and referral of malnourished children and women
March 2016 onwards
DoH focal person Nutrition focal person
Design and participate actively in the mid-term and end term evaluations
Evaluation reports June 2018 June 2020
DoH, Technical partners
Intermediate Outcome Indicator 2:
Baseline YR 3 Target (2018)
YR 5 Target
(2020-21)
Frequency of Collection
% of infants 0-6 months of age for whom breastfeeding was initiated within 1 hour of birth27
61.8% 70% 80% Annual HMIS and NSS28
Output 2.1.: “Protection of Breast-Feeding and Child Nutrition Ordinance” enforced from all private and public sector facilities
Activities MoV Deadlines Sectors
Lobby with policy makers /legislators and media through campaign for development and effective enforcement of “Legislation of the code of marketing of breast milk substitute”
- Report/clips of media campaign
Sept. 2016
Nutrition cell
Policy makers particularly women caucus,
Legislators
Registered hospitals and BHU / FWC/ MSU/RHC would implement the bill and ensure that the formula milk are only prescribed in extenuating circumstances
- Field monitoring report
Dec. 2016
onwards
CSO representatives/ media
Intermediate Outcome Indicator 3: Baseline YR 3 Target YR 5 Frequency of
27 NNS 2011- PAGE 84 28 NSS: Nutrition surveillance system
19
(2018) Target (2020) Collection
% of infants aged 0-23 months of age who received exclusive breastfeeding up to six months of age29
14.5% 40% 70% Annual HMIS and NSS
% of children aged 12-24 months who were introduced to complementary food between 6-8 months of age30
51.3% 60% 70% Annual HMIS and NSS
Output 3.1.: Knowledge and competency of the health care providers strengthened in IYCF
Activities MoV Deadline Sectors Budget
Establish a task force comprising of representatives from PMDC,
pediatrician, nutritionist and nurses to define the strategies for inclusion of
IYCF in the curriculum and practice guidelines of the doctors. The in
service training MBBS curriculum should also sensitize doctors about the
harmful health effects of pesticide.
Notification of
the task force
June 2016 DoH Nutrition PMDC
Not needed
KAP survey designed and implemented in mid year and end year to
assess the improvement on knowledge about IYCF amongst health care
providers when compared with baseline.
KAP survey
report
June 2018 Dec. 2020
DoH Nutrition Research org. Technical partners
Needed
29 NNS 2011 PAGE 85 30 NNS 2011 -2013 fig. 7.5.
20
Intermediate Outcome Indicator 4.0 Baseline YR 3 Target (2018)
YR 5 Target (2020)
Frequency of Collection
% of mothers with a child aged 0-12 months who received any ANC during their last pregnancy31
80% 85% 90% Annual HMIS and NSS
% of mothers with a child aged 6-24 months who received micronutrient supplements during the last six months of her last pregnancy
33.3% 45% 55% Annual HMIS and NSS
Output 4.1 Competency of health care providers would be enhanced in BPCR and preconception counselling to provide good quality of antenatal
care
Activities MoV Deadlines Sectors
- BPCR and Pre conception counselling curriculum will be
developed with emphasis on maternal nutrition and its
implication on the new born babies
Copies of the approved
curriculum
September 2016 DoH and sub sector
- All the Primary health care centres ‘ staff and those
working in PWD clinics iin the marginalized areas will be
trained to provide pre-conception and BPCR counselling
to married couples through LHW, CMW, EPI and FWW
platform to ensure that new born is nutritionally health
Training report
March 2017
DoH and sub sectors, Population welfare
department
- All cadres of health care providers (LHWs, CMW and
FWW) would be trained to deliver messages about
adolescent nutrition, anemia prevention in young adults,
healthy cooking, dietary eating practices.
Training report
Dec 2017
DoH and sub sectors
PWD
31 in I n t e r - S e c t o r a l C o n s e n s u s B u i l d i n g O n Nutrition Strategic/Operational Planning, October 3-4, 2012, Serena Hotel Gilgit page 11
21
Intermediate Outcome Indicator 5.0 Baseline YR 3 Target (2018)
YR 5 Target (2020)
Frequency of Collection
% of children aged 12-60 months who received vitamin A supplement in the past 6 months
-
80% 90% Annual HMIS and NSS
% of children aged 6-24 months who consumed multi-micronutrient powder during the past week
- 30% 40% Annual HMIS and NSS
Output 5.1: By 2018, KAP survey will indicate that parents of under five children and school teachers of pre- nursery/nursery schools have 50% more
awareness compared to baseline about prevention, signs and symptoms and the importance of seeking timely care for malnutrition and other
childhood illnesses such as diarrhea and Pneumonia
Activities MoV Deadlines Sectors
CMWs, LHWs, EPI and outreach worker's (Agriculture extension
workers, school curriculum, WASH worker's and WDD workers)
curriculum would be revised to include key messages around nutrition.
Copy of the revised
curriculum
Dec. 2016 Nutrition, DoH sub sectors, such as
CMW, LHW, EPI, Dev..partners
Technical expert
CMWs, LHWs, EPI and outreach workers would receive training to
enhance competencies to transfer skills and exploit opportunities for
educating parents around those key messages.
Training evaluation
report
June 2017 Nutrition, DoH and tertiary care facility,
CMW, LHW, EPI, Dev..partners,
Technical expert
Create models of Public-Private Partnership, to reach out to the
population in the uncovered areas using different platforms
Coverage report
Dec 2017
Private sector
Nutrition cell
DoH
Mass communication campaign will be designed and rolled out to
reach out to the population with nutrition promotion messages
Campaign report June 2017 Nutrition, DoH, CMW, LHW, EPI,
Dev..partners, Technical expert, BCC
specialist
One stabilization unit with CMAM facility unit will be established in
each district and will be linked to OTP. Free indigenously prepared
Nutrition information
system
June 2016 NSS, DoH
22
nutrition supplements will be made available for nutrition
deficient ultra poor ladies/children.
Output 5.2. Prevalence of Vit A deficiency amongst children under 5 years of age will reduce from 71.8% to 50%
Activities MoV Deadlines Sectors
Awareness raising campaigns and activities will be implemented for promoting healthy diet amongst women of less than 5 year old children which includes consumption OF green leafy vegetables and fruits
Campaign report Dec. 2016
DoH, Nutrition cell, Dev. Partner, BCC specialist
Ensure availability of micronutrient supplies of Vit A supplementation for administration during Polio and other such mass vaccination campaign
Mass vaccination program activity report
June 2016
Polio program Nutrition cell Dev. Partner
Introduce indicators to monitor the coverage of Vitamin A from different areas by including a separate indicator in its DHIS.
Vit A coverage report Dec. 2016
Dev. Partner, BCC specialist
Polio department, MIS department
Intermediate Outcome Indicator 6.0 Baseline YR 3 Target (2018)
YR 5 Target (2020)
Frequency of Collection
% of union council covered by LHWs, CMWs, NGOs or CSOs
- - Annual HMIS and NSS
Output 6.1. High risk UC identified and mapping of the local resources undertaken
Activities MoV Deadline Sectors
Mapping of the high risk UCs its gaps and
existing resources including LHWs, CMWs
carried out
Report covering the gap
analysis and existing
resources
April 2016
DoH and sub sectors, Technical expert, LHW program, Dev. partner
23
Capacity building plan will be developed for
enhancing coverage of integrated health
and nutrition services in these areas
Copy of the plan June 2016
DoH, Technical expert, LHW program, Dev. partner
Output 6.2. Improved effectiveness of LHW in high risk UC which are LHW covered
Activities MoV Deadline Sectors
A task force will be formed to undertake a
critical review of the LHW program, its
challenges particularly related to logistics and
medicines, bottlenecks and address gaps to
revive the program
Report of the task force
June 2016 DoH Technical expert LHW program Dev. partner
Nutrition indicators in the current LHW- MIS
will be critically analysed and proposal
submitted to improve the scope and quality of
information being forwarded on real time
basis to ensure timely actions
Revised tool Dec 2016 DoH Technical expert LHW program Dev. partner
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DEPARTMENT OF AGRICULTURE/FOOD/LIVESTOCK/POULTRY AND FISHERIES
SUMMARYOF AGRICULTURE SECTOR SPECIFIC RECOMMENDATIONS
Action area 1- Creating enabling environment
Recommendation 1.1: Enhance food security through approving and enforcing integrated pro-poor gender sensitive provincial agricultural and food security policy
Recommendation 1.2: Increase production of diverse sources of food through upscaling innovative partnership approach
Action area 2: Capacity Development and coordination
Recommendation 2.1: Establish food authority to ensure food safety of the food products, pesticide and fertilizers available in the market
Recommendation 2.2:Ensure safety of medicinal inputs for treatment, enhancing milk and meat production of the livestock
Recommendation 2.3: Improve the effectiveness of the role of agriculture extension workers to enable beneficiaries particularly marginalized ones to produce more crops and
contribute to enhancing food security.
Recommendation 2.4: Enhance the skills of the outreach workers to enable them to perform their responsibilities as multi-skilled, agricultural extension competent to influence
the knowledge, attitude and skills of the farmers, livestock growers and fishery owners by strengthening their competency in respective areas of work.
Recommendation 2.5:Enhance the capacity of existing capacity of the livestock extension workers training units
Recommendation 2.6. Food security monitoring section to be established in the Live stock department
Recommendation 2.7: Engage and empower underserved women to develop locally tailored healthy food, produce diverse sources of food and adopt processing techniques' for
perishable food items.
Action area 3: field level implementation
Recommendation 3.1: Upscale fish farming capacity particularly in small fish farmers through financing and provision of better quality inputs
Recommendation 32: Home stead food production of livestock, dairy and poultry products upscaled through extending micro finance and micro credit loans to poor and
marginalized
Recommendation 3.3.Improved intake of good affordable protein through increased awareness from various platforms about benefits of eating fish and meat
Recommendation 3.4: Role of the food department expanded and synergies built with other sectors to ensure availability of fortified food
Recommendation 3.5: Ensure availability and access of affordable and quality supply of pure seeds to farmers in GB through investing in research for varietal evaluation
Recommendation: 3.6. Revive fish farming in GB with support of the private sector
Action area 4: Research and development
Recommendation 4.1: Research and advocacy fund established with participation of sectors in the technical advisory group. Here do you mean the TWG? Or a TAG?
25
Result framework for actions from agriculture/livestock/fisheries sector
Annexure 3: Agriculture/livestock/fisheries Matrix
Key Agriculture/livestock/fisheries/Food Sector Indicators NNS 2011 NNS 2018 NNS 2020 Source
% of households “food secure”32 60% 70% 85% Nutrition survey
% of children consuming at least four of seven food groups on the previous day 45% 65% Annual monitoring and NSS
% of landless or small holder rural households reached in the past 6 months
with assistance in garden production, small livestock or fisheries
- 40% 70% Annual monitoring via MoA
management information system
% of commercial wheat flour-consuming households consuming fortified wheat
flour
- 30% 50% Annual surveillance
site data
% of commercial edible oil-consuming households consuming fortified edible oil - 30% 70% Annual surveillance site data
% of households consuming iodized salt (min 15 ppm) 85% 90% 95% Annual surveillance site data
% of poultry famers and livestock breeders producing better quality of eggs,
meat etc
- 50% 70% Annual surveillance site data
Intermediate level outcome 1 Indicator 2018
Indicator 2020
MoV
% of food secure households increased 70% 85%
KAP survey
Output 1.1: Gender sensitive and pro-poor provincial , livestock and food security policy enforced.
Activities Means of verification
Timeline Sectors
32 Source: NNS 2011
26
Advocacy and lobby to the legislator for food security policy Collection of information and research data for policy advocacy
Approved food security
policy
June 2016
DoA All stake-holders Civil society
Output 1.2: Several public private projects (PPP) are implementing interventions to increase access and supply of the diverse sources of food in the
marginalized population
Activities
Means of verification
Timeline Sectors
Establish a task force to develop ToR for public private partnership projects (PPP) projects
-Mechanisms are in place to protect private sector’s commercial risk, policy risk and regulatory risks
- ToR for PPP around food fortifications
Dec 2016
DoA
Private sector
Intermediate level outcome 2.0.
Indicator 2018
Indicator 2020
MoV
Enhanced level of knowledge, attitude and skills amongst farmers,
livestock growers and fishery owners about good practices for
farming, cattle rearing, poultry and fish and fishling resulting in
increased production and reduced post harvest loss.
40% of the farmers, livestock
growers and fishery owners
70% of the
farmers, livestock
growers and
fishery owners
KAP survey
Output 2.1 : >95% of landless or small holder rural households reached in the past 6 months with research, technical and financial assistance in
garden production, small livestock or fisheries
Activities Means of verification
Timeline Sectors
- Strengthening of Human resource development centre (physical and technical infinrastructure) to enhance the capacity of >95%% of extension workers and field assistants all subsector of agriculture (agriculture, poultry, livestock and fisheries)
Annual monitoring report DoA information system
June 2017 DoA- training department Technical expert
27
- Nutrition component added to the master trainers curriculum and approach to learning strengthened with inclusion and emphasis on backyard gardening, importance of consuming all food groups for health and establishing and maintaining small scale livestock and fishery
Revised curriculum Annual monitoring report
Dec. 2016 Technical experts
DoA
- Innovative approaches such as hotlines will be developed to provide access to updated knowledge about safe and good quality farming inputs including small level fish farms
Annual monitoring report
Dec. 2016 DoA
IT experts
- Financing schemes based on easy conditions will be developed by Waseela-e-rozgar programme / social welfare program / ZaraiTarqiyati bank to provide initial small credit and financing packages and extended to small farmers and agriculture producers to promote aquaculture practices and backyard fish farming
Financial products Annual monitoring report
Dec. 2016
DoA Financial institution BISP
Better quality, affordable, safe and certified fish feed that enhances the nutrient values and good protein availability of the fish protein as a result of research will be available to small and poor farmers at affordable price
Market survey
report
Dec. 2016
Research organization
Micro credit loan provider
Standards will be set for certifying safety of medicines and hormones used for enhancing milk and milk products
Copies of the
standards
Dec. 2016
Technical assistance
Dev. Partners
Methods to improve poultry farming (meat and egg production) introduced
DoL report
Dec. 2016 Technical assistance Dev. Partners
Improve the national breed improvement program enhance the quality
of livestock through cross breeding of the cattle with better genetic
endowment;
Research
development report
June 2017
Academia
Research experts
DoA
R&D to produce better quality of seeds, plant varieties, women friendly
technology and safe medicinal inputs in dairy farming
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Intermediate level outcomes 3.0:
Indicator 2018
Indicator 2020
MoV
% of commercial wheat flour-consumers/households consuming fortified wheat flour
30% 50% Nutrition Survey
% of commercial edible oil-consumers/ households consuming fortified edible oil
30% 70% Nutrition Survey
% of households consuming iodized salt (min 15 ppm) 90% 95% Nutrition Survey
Output 3.1: By 2016, Food department with support from Pakistan Standards and Quality Control Authority (PSQCA), legislators and CSOs will ensure that fortified food items are available in the market
Activities
Means of verification Timeline Sectors Budget
Food inspectors inducted in the food department to enhance vigil on the sale of fortified food in the market.
Market survey report from the
food department
June 2016
Food Department PSQCA
Needed
Certification at the products from down country to GB will be enforced with support from the law enforcement agencies posted on the border.
Market survey report from the food department
June 2016
Food Department PSQCA Consumer protection bodies
Needed
Mass media will be mobilized to create wide spread awareness about importance of consuming a balanced and healthy diet along with consuming fortified food, meat and fish items in the market.
Clips/records of mass media
awareness
June 2017
DoA and DoLs Manufacturers Private sector CSO Mass Media
Needed
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Intermediate level outcome 4.0.
Indicator 2018
Indicator 2020
MoV
% of children consuming at least four of seven food groups on the previous day
45% 65% Annual monitoring and KAP survey
50% of the farming women will be growing and processing variety of foods for family consumption and sale.
50% 70% Annual monitoring and KAP survey
Professional and technical capacity building of private sector fish farmers to enhance their productivity
50% 70% Annual monitoring and KAP survey
Output 4.1 : Social marketing and awareness campaign would be launched to create awareness amongst parents and population about eating
diverse sources of food
Activities
Means of verification
Timeline Sectors
Massive social Marketing campaigns instituted to promote fish and meat consumption culture across the province
Mobilize various community based actions such as fish days or meat days to create awareness about benefits of consuming these sources of meat and protein.
Campaign reports IEC material
June 2016 DoA, livestock and fisheries
DoH-Nutrition cell
Technical agencies
:
30
11.0. DEPARTMENT OF WATER AND SANITATION
SUMMARY OF WATER AND SANITATION SPECIFIC RECOMMENDATIONS
Action Area 1: Enabling environment, policy frameworks, strategies
Recommendation1.1: Create enabling environment for the provision of safe water and sanitation through instituting policy and strategy
Recommendation 1.2: Create enabling environment through adopting an inclusive process that ensures women at the centre of designing
and follow-up support for all water supply, sanitation and hygiene schemes to make it more gender sensitive.
Action Area 2: Capacity building
Recommendation 2.2: Strengthen the service provider's ability to provide safe water and sanitation
Action Area 3: Field-Based Implementation
Recommendation 3.1: WASH sector in collaboration with other sectors (public and private partners) would raise awareness about importance of
maintaining WASH schemes in good condition and adopt appropriate health and hygiene practices including hand-washing.
Recommendation 3.2: Incorporate community oversight monitoring and supervision of the water and sanitation system through building community
ownership and commitment to provide follow up care to WASH interventions
Recommendation 3.3: Review and strengthen health and hygiene promotion messages in the curriculum of different sector’s outreach workers
Recommendation 3.4: Increase access to safe water and sanitation through adopting a systematic plan of introducing new schemes and rehabilitating
already instituted schemes in the prioritized UCs/districts
Action area 4: Research and development
Recommendation 4.1: To undertake research activities to collect evidence for policy advocacy and developing feasible interventions.
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Result framework for actions water and sanitation sector
Intermediate level outcome 1 Baseline Indicator 2018
Indicator 2020
MoV
Increased % dwellings will have piped or tubewell/boring water
Increased % households have access to hygienic sanitation facilities 73% 80% 90%
Survey report
Output 1.1: Provincial water policy and strategy and sanitation policy and strategy are approved and enforced.
Activities Means of verification
Timeline Sectors
Lobbying and advocacy to legislators for approval of Water and sanitation policy;
Copy of approved provincial
water policy and strategy
June 2016
WASH
Legislative department
Activities Means of verification
Timeline Sectors
Implement gender-sensitive WASH interventions along with other sectoral interventions (pipe networks, water treatment units, sanitation system sewage treatment) in prioritized, marginalized area
Physical survey report of hard to
reach areas
June 2016 WASH
Legislative department
Community Operation and Management groups would be instituted for every new schemes to ensure these are functional after five years
Physical survey report of hard to
reach areas
June 2016 WASH
Legislative Dept.
New WASH scheme would seek village consultation from
women groups and foras during planning process Physical survey report of hard to
reach areas
June 2018 WASH
Rural Support Prog.
Establish intra sectoral monitoring cell to ensure that water and sanitation schemes meet the minimum required standards;
Annual report June. 2016
WASH tech. experts, Environment specialist, Water quality assessment laboratories
A system of a fortnightly water quality testing from each UC
for safety and quality
MIS from water system June 2016
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Intermediate level outcome 2 Baseline Indicator 2018
Indicator 2020
MoV
Households have soap available at the washing place 17% 55% 70%
KAP survey
Output 2.1: Awareness raising about hand washing amongst population
Activities Means of verification
Timeline Sectors
A multisectoral expert group will develop key messages about
hand washing, hygiene of sanitation facility and proper disposal
of solid waste
Report of formative research June 2016 DoA All stake-holders Civil society
Clear and focused BCC strategy will be implemented through
schools, outreach workers and mass media campaign to
promote health and hygiene messages
Report and news clips about
the advocacy campaign
Dec. 2016 DoA BCC specialist
Environmental hygiene and personal hygiene related messages
will be incorporated in the school curriculum with WASH sector
providing necessary support if needed
Copy of the school curriculum Dec. 2016
DoA DoE Nutrition expert
33
RESULT FRAMEWORK : KEY EDUCATION AND WOMEN SECTOR
Key Education and Women Sector Indicators
Baseline
2011
Indicator 2018
Indicator 2020
MoV
% of schools including nutrition in school curricula at any level
- 45% 95%% Annual DoE management information system data
% of secondary schools offering life skills education and weekly iron tablets to adolescent girls
- 25% 60% Annual DoE management information system data
Output 1.1: 30% more children from marginalized families (source: BISP/AKRSP database) will complete their primary schooling
Activities Means of verification
Timeline Sectors Budget
Mapping of the schools in high risk areas with low girls
attendance; Mapping report June . 2016
DoE Academia Researchers
Needed
Formative research undertaken to identify barriers to school
attendance amongst girl children Formative research report June 2017
DoE Academia Researchers
Needed
Introduce incentives such as food vouchers to poor families
registered in BISP database to encourage them to send
their children to schools
Quarterly report of the food
vouchers distribution
Dec. 2016
onwards
DOE/School management committee/ private sector philanthropists
Needed
The information system will have district wise nutrition
indicators about school enrolment, school retention and
promotion to next class indicating the effectiveness of the
intervention;
Quarterly DEIS report Dec. 2016
DoE MIS department
Needed
34
Output 1.2: 70% Children from marginalized families attending schools in high risk districts receive mid day food as incentive and also to improve
school attendance
Activities Means of verification
Timeline Sectors
Lobby for instituting policy for mid day food
Media clips or info briefs used for
lobbying Dec 2016
DoE CSO
Policy on mid day food enforced and implemented in the
high risk districts on priority basis
Copy of the approved policy
June 2016
DoE Legislative body
SMC’s will receive training to develop community
mobilization strategy, process of procurement and
distribution strategy for the mid day meal;
Training report
Copy of the Strategy document
Sept 2016
DoE BCC specialist CSO
Project monitoring system will be instituted to ensure
transparency of the mid day food program
Project monitoring team report
June 2016 DoE /CSO
Schools will organize awareness activities for children about
benefits of eating a healthy diet and health and hygiene
alongside distribution of mid day food.
Awareness campaign reports
News articles
Dec 2016 DoE
CSO
By June 2017, 70% of schools in the target districts and
UCs will get a glass of milk daily with a fruit or some dry
biscuits
Report of the implementation of the
mid day food program
June 2017
DoE / P&D/ SMC/Private Sector
Intermediate level outcome 2 Indicator 2018
Indicator 2020
MoV
% of schools including nutrition in school activities from the curricula 45% 95%% Annual DoE Management information system data
Output 2.1: Development and inclusion of nutrition promotion activities school curricula
35
Activities
Means of
verification
Timeline Sectors
A task group comprise of educationist and nutritionist would be established
to identify gaps in the school curriculum for nutrition component and
propose standardized action oriented nutrition activities
Curriculum review
report
June 2016 DoE
DoH-
nutritionist
PDCN will develop curriculum for building capacity of SMC33 and MSG34 Copy of the
curriculum
Sept 2016 DoE, PDCN Curriculum review
department
Seek approval from approving authority on the inclusion of the proposed
sets of activities in the revised curriculum
Copy of the approval
from the designated
authority
Dec 2016 DoE, Curriculum review
department
Proposal approved for provision of budget for reprinting as well as building
of the skill lab for students to inform students about the nutritious diet
Budget approval
notification
Dec. 2016 DoE, P and D
DOE with support from UNICEF and FAO will incorporate community
based activities including kitchen garden in the school curriculum
Survey report June 2018
DoE, SMC, FAO
Agriculture extension workers
Schools will identify community areas that can be used for developing
kitchen garden
Children will be asked to bring seeds from home or get it from the
agriculture extension farmers and plant it in the school garden and learn
the skill of producing vegetables and fruits.
Intermediate level outcome 3 Indicator 2018
Indicator 2020
MoV
33 School Management Commitee 34 Mother support groups
36
% of secondary schools offering life skills education and weekly iron tablets to adolescent girls
25% 60% Annual DoE management information system data
Output 3.1: : Upscale schools on child friendly school concept across Gilgit-Baltistan with priority in hard to reach areas
Activities Means of verification
Timeline Sectors
Mapping out schools for prioritizing schools for up-gradation to child friendly school
Survey report June 2016
DoE / AKES Technical assistance
DoE will link up with agriculture sector for technical assistance and access to inputs i.e. seeds for enabling students to learn to grow community and school backyard garden;
DoE performance report
Manual on building community garden
Dec. 2016
DoE DoA
DoE will link up with LHWs in the catchment area of the school for skill development activities, annual health screening of children, de-worming of children, and school health screening.
DoE performance report
School health screening report Dec. 2016
DoE DoH-LHW program Civil Society
Teacher’s trainers would be equipped with latest
knowledge and skills of nutrition education and
administration of iron tablets
Training report Dec. 2016
DoE PDCN
90% of the schools in GB would have “Parent teacher
committee/ SMC” active and ready to take
responsibility to monitor the functioning of the school
drinking and washing facility
School survey report June 2018
DOE Parent community
90% of the schools in GB would have functioning
water and sanitation and hygiene system
School survey report June 2020
DoE Engineering deprtt Parent teacher committee members
Output 3.2 : Strengthen the role of mothers support groups in creating healthy conditions for nutrition and health in schools and homes.
37
Activities
Means of verification
Timeline Sectors Budget
Mothers support groups established in all
educational institutions of GB
Mothers support group should be prepared to extend support in creating awareness about healthy nutrition amongst parents of the children.
Performance report of MSG
Plan of MSG activities
Dec. 2016 DoE MSG LHW Private sector
38
CROSS CUTTING SECTOR
39
14.0. CROSS SECTOR ONE: WOMEN DEVELOPMENT DEPARTMENT – (WDD)
“Women Development Unit” is a project based in P&D until 2001. In 2006-7, the scope of WDD enhanced to include focus on the
status of women, promote women's rights, ensure their active participation in provincial life at all levels, facilitate their serving as
agents of change in society, and to improve their legal access to economic resources and employment. WDD also has a sub-office
established at Skardu. In 2014, the project achieved the status of “Women Development Directorate” (WDD) with its mandate to
focus on “Gender growing issues” in GB.
Role of WDD in addressing nutrition problem
WDD through its mandate to empower women at social, economic and political level can play a very powerful role in improving
women status- one of the underlying determinants for good nutrition. By prioritizing its intervention in the most high risk areas, the
department can play a key role in reducing gender inequality.
Role of WDD in improving malnutrition
NNS 2011 data presents a mixed picture of women status in GB. Although according to NNS 2011, 80% women attend ante natal
care (ANC), PDHS 2012-13 shows a lower coverage of 64%. The education level of girls demonstrates gender parity of 0.73
indicating inequity in access to education. NNS shows that 31 percent of women in GB had 6 or more pregnancies (higher than the
national average 24%) and 35% women reported anemia. Prevalence of severe Vitamin A deficiency is as high as 32%. In GB, more
than one third of the households are food insecure and women are most affected in these households in terms of nutrition. Social
customs and role definition of women that subscribe hard labour for women, practice of eating last, bearing many children, little
control over finances, social marginalization with limited decision making power has its effect on overall health and nutrition of
mothers and their off springs.
Such dire situation puts huge responsibility on WDD to mobilize Government support, to enhance women status ensure creating an
environment which allows very sectors to work effectively for improving adolescent and child bearing age women social, physical,
psychological and nutritional status. WDD does get into direct service delivery for women such as vocational training programs for
women, it also understands its role in creating models of empowerment of that could be scaled up in other areas of the region.
40
Action 1: Create an enabling environment for action
Recommendation: WDD should aim to build strong and sustained government commitment, through developing favourable policy
environment, and allocating and timely releasing resources for improving women status based on the agreed plan
OUTCOME INDICATORS
By June 2017, policies and legislations will be in place for providing an enabling environment for women development
PROBLEM AND RATIONALE
Opportunities for income generation are vital for empowering women. Laws, counseling, support services, and medical care are quite
important for prevention and management of gender-based violence and discrimination particularly in those areas where women
traditionally have a very low social status such as in certain parts of GB. Lack of availability of schools and female teachers pose
cultural constraints to girls’ education. Likewise, in the area of health care, lack of availability of functional health services with
women provider pose other threats to women’s life and her ability to take timely care for various conditions affecting her health.
Women caucus and women development directorate can provide excellent forum for raising awareness and mobilize support for
action to enhance women’s status. Forum could advocate law and legislation as well as enforce legislation for prevention of domestic
violence and sexual harassment as well as preventing discrimination. In addition, advocacy by women caucus for equitable
distribution of health services will have huge bearing on the decisions around resource allocation from ADP and for innovative
approaches to reaching out to poor women including through mobilization of religious leaders, council members and women
legislators.
PROPOSED ACTION:
WDD should:
undertake impact assessment of its income generating interventions on health and social status of women to enable policy
makers to understand the value of allocating more resources for scaling up such initiative to reach out to as many areas as
possible;
41
advocate and lobby to the women legislators to35 develop mechanisms that provides free legal aid to women who are victim of
domestic violence and sexual harassment;
Expedite the establishment of Family Protection Centre (Crisis Centre for Women in G-B) and link these with income
generation capacity building of the inmates.
Form public policies and laws to assure full female access to education and health services
Ensure that summary of every maternal death is reported to WDD to ensure that barriers to care are identified and
addressed through advoacy
Protection and promotion of women's rights relating to employment and inheritance and social protection
WDD should join hands with other sectors in lobbying for:
o availability of female health care providers in the rural areas through agreements with the academic institutions by
adopting mandatory rotation of physicians;
o establishment girl friendly schools such as establishing girls madrassah schools, scaling up of home schools and
platforms such as “religious dars meeting” to promote women status, culture and practices in light of the Islamic
teaching
WDD should become the voice of people in particular women through developing sensitization package comprising of
advocacy seminars and newsletter that sensitize legislators, council members and policy makers about issues confronting
women and the actions needed.
WDD should organize advocacy training for journalist and other media personnel including for the female political member at
municipal, union and district level each year to promote and present performance of the WDD and advocate on women’s
rights and issues in GB
ACTION AREA 2: CAPACITY BUILDING AND COORDINATION
Recommendation: WDD should aim to expand its vocational training to be integerated with other support service and focus
on nutrition related businesses trade also
42
OUTCOME INDICATORS:
By June 2017,
WDD will have at least five more nutrition skill based vocational training program in its list of training
More than 70% of the graduates from vocational training centres would be gainfully employed or have their small business
with at least 30% increase in their monthly income
PROBLEM AND RATIONALE:
Review of the current programs of WDD highlights more vertical nature of intervention such as emphasis on vocational training that
builds women skills with an aim to enhance income generating capacity of women. The review of the documents however did not
highlight any arrangements for placement or marketing of these skills.
Women social status has a key role to play in improving nutritional status of women. WDD is working to enhance livelihood
opportunities through 68 vocational training centers established across Gilgit Baltistan in all districts. 6000 women from 110 villages
of G-B have been trained in basic vocational training certificate courses and 100 girls have been trained in short technical courses
e.g. Emboss painting, glass painting, fabric painting, tie & dye. Unfortunately, assessment of how household income has impacted
upon women’s health and nutrition status have not been carried out.
PROPOSED ACTION
WDD would build a network of business organizations, corporate, representatives from health, agriculture, education, mcro-
finance and private investors to enable WDD to identify emerging needs and potential market and placement for such
individuals.
WDD should expand the range of courses in light of the feedback received from stakeholders. It is desirable for WDD to
include vocational training program that enable availability of diverse sources of foods such as jams, jelly, etc. In the market
or products which indirectly contribute to enhancing health such as soap making.
WDD should map out the most high risk areas for women empowerment and poverty. It should develop a coordinated plan
with other private sector investors such as Hashoo foundation and AKRS, P to take these skills to the areas where it is not
possible to reach by WDD through its own resources.
43
Vocational training platform should also be used for educating women about their own health, child health and nutritional
health.
Promotion of cottage industries which boost women’s employment and household income and control on food choices
Map out and prepare a database of all the organization in GB for women gender equity
ACTION AREA 3: FIELD BASED IMPLEMENTATION
Recommendation: WDD should celebrate women’s and children international day in collaboration with other sector
focusing on how women’s social status, nutrition status and education status could lead to better health for family
RESULT OUTCOME
By June 2017:
WDD would lead twice a year campaign on women issues and development primarily from rural areas
WDD will support other sectors in organizing and launching their campaign
PROBLEM AND RATIONALE
Malnutrition in women and girls is directly linked to societal norms and practices. Women status, her mobility, cultural restriction on
her travel all pose a barrier to her development, which indirectly results in poor nutrition and health outcomes. The society considers
investment in son's education and food to be a worthwhile investment as they are expected to be the main bread winner and
responsible for procreation. Gender role and poverty further translate into higher prevalence of intra house power dynamics such as
restricting daughters after 12 years to move out of the house in some of the ethnic and conservative community needs to be
addressed on a priority basis using a women friendly and socially acceptable platform. It is important that priority for such
sensitization campaigns is given in hard to reach areas where the need is more instead of carrying it out in urban areas like Gilgit.
PROPOSED ACTIONS
WDD should celebrate Women’s International day each year with following points in mind:
Give priority to more rural areas
44
Adopt an integrated approach so that almost similar yet different messages are disseminated from various platforms
such as Mother and child days, enrolment campaigns from education and women social status up-liftment from WDD.
Inform communities about opportunities available to women to seek micro credits and loans for enhancing their small
ventures
ACTION AREA 4: RESEARCH
Recommendation: WDD should carry out researches to advocate for evidence based interventions to address unmet needs
for improving women’s health and nutrition
RESULT OUTCOME
By June 2017, WDD will develop and get funding for its research agenda approved
By Dec. 2017, WDD would have launched at least one research that will generate knowledge and evidence for improving
health and nutrition of women and children
PROBLEM AND RATIONALE:
Advocacy activities can only be effective when it is evidence based collected through relevant and context specific research
activities. It is important that WDD undertakes women oriented research activities that can lead to policy action:
1. Research to understand barriers to improving nutrition amongst women
2. Knowledge development and dissemination around models of governments and non-governmental models of health and
nutrition services for reaching out to women in rural areas
3. Trends in the emerging market for enterprise development with women and girls in the center of such development;
4. Collection of best practices of improving women status in rural mountainous areas
5. Review of the current vocational training curriculum to incorporate nutritional component in there
6. Collection of case studies to improve awareness about human & women’s rights issues that ultimately impacts upon the
health of the women.
Action area 5: Project Management, Reporting, Monitoring and Evaluation (for nutrition-related and nutrition-specific
interventions)
45
Recommendation 5.1: Develop, monitor and report the progress on various programs to ensure coordination with other players
RESULT OUTCOMES
By June 2018, WDD in coordination with various departments will achieve 70% of the planned activity
PROBLEM AND RATIONALE: WDD plans and actions are very activity oriented and therefore will need to develop some impact
indicators which can be assessed at five year interval. These impact indicators would very much depend upon receiving the support
from various departments. WDD by participating actively in oversight monitoring forum will be able to gather the required support.
PROPOSED ACTION
1. Develop MoU with different sector to agree on potential role;
2. Develop indicators in consultation with participating sectors to report to oversight committee
3. Develop action plan and milestones with timelines and report it on a quarterly basis to the oversight committee
4. Identify red flag issues with reference to joint intervention or road blocks and see support from the forum.
46
15.0: CROSS SECTOR TWO: SOCIAL PROTECTION AND POVERTY ALLEVIATION
There is a widespread perception that malnutrition is closely related to poverty. Poverty is one of the underlying determinants and
basic causes of malnutrition identified in UNICEF causality framework 36 . Persistent malnutrition also leads to ill health, poor
education performance, low labor productivity and poverty. The data from NNS 2011 indicates that large family size and low income
has close linkage with stunting. Study shows that stunting is higher (53.1%) in the lowest quintile group, but it also exist in the highest
quintile (28.9%) and is mainly related to behavioral issues in this group37.While the relationship cannot be denied, it is complex. It
must also be recognized that nutrition is more than food, and poverty is more than mere income or assets. The poverty-nutrition
interaction in Pakistan is particularly strongly influenced by female social status which mostly affects girl child and other determinants
including education status of the population and access to safe water and sanitation intervention.
Social protection is one of those strategies concerned with preventing, managing, and overcoming situations that adversely affect
population well-being[1] Social protection consists of policies and programs designed to reduce poverty and vulnerability by promoting
efficient labor markets, diminishing people's exposure to risks, and enhancing their capacity to manage economic and social risks,
such as unemployment, exclusion, sickness, disability and old age.
Benazir Income Support Program (BISP) is the Pakistan’s 1stlarge scale national social protection program, launched in October
2008 through parliamentary act to cope with increase inflation after 2008 global economic crisis38 with the intention to assist 40% of
population below poverty line39. In the social protection area, the country has introduced cash transfer to families through BISP, but
there has, to date, been little effort to orient the program toward nutritional concerns – either through the provision of nutritional
supplements or counseling. TAWANA – well functioning school feeding programs – had sought to adopt an inter-sectoral approach
by developing a tripartite agreement among the Ministry of Social Welfare, the Ministry of Education and the Ministry of Women
Development. TAWANA, however, has faced numerous problems to date.
BISP is one and probably the only social welfare initiative currently active in GB. Target population for BISP is mother of poor
households. Initially BISP was an unconditional cash transfer program but as unconditional cash transfers found to increase
dependency so BISP took a step towards conditional cash transfer by introducing Waseela-e-Taleem, Waseela-e-Rozgar and
36http://www.unicef.org/nutritioncluster/f...nutritionTechnicalNotes.pdf
37 Inter-Sectoral Consensus Building On October 3-4, 2012, Serena Hotel Gilgit
38 Benazir income support program (http://www.bisp.gov.pk)(accessed 20/5/2013)
39 Ibid
47
Waseela-e-Sehat. Intersectoral nutrition strategy proposes to advance or remodel following components in achieving the effective
implementation of the program:
Waseela-e Rozgar program:
Social protection policies generally has both active and passive component. Passive component in the form of unemployment
benefits etc. is currently not present. These components are not designed to improve their employability. The second component
which is active social protectionis aimed atincreasing the access of unemployed workers through providing them the opportunities
to participate in vocational skills or micro-finance to reduce the risk of unemployment and to increase the earnings capacity of
workers. BISP has included this in the form of “waseela-e rozgar” program.
Proposed role of waseela-e rozgar in INSGB
The strategy envisage BISP expanding vocational training component to include skill development options in the area related to food
and nutrition such as food processing, backyard poultry hatchery management, community based veterinary workers training etc.
These trainings should primarily target women beneficiaries and translate into reducing household food insecurity and access to
diverse source of food in the market
Social Insurance:
Social Insurance component included in the BISP is in the form of “Waseela-e-Sehat” and Waseela-e Taleem. Purpose of these
components is to mitigate the risks associated with poverty by providing access to health care and education.
Proposed role in INSGB
INS-GB advocates that Waseela-e- Sehat program should be expanded to reach out to those areas where currently the program
services are not available and population is poor. Under this program, life insurance cover of Rs 100,000 has been provided to the
bread winners of one million beneficiary families since January 1, 2011 while Health Insurance for all beneficiary families is being
launched in selected four districts. It is strongly recommended that the facility is expanded to selected high risk districts of GB to
protect poor families from such catastrophic shock and prevent them from dipping below the poverty line.
Social Assistance component:
48
Social Assistance component of BISP social protection program includes transfer of cash to vulnerable individuals or households
with no other means of adequate support. This component is included in the current package in the form of cash transfer to the
female head of the family. Such unconditional cash benefit has been critiqued immensely by intellectuals in GB on the basis that it
creates a sense of dependency amongst beneficiaries.
As an exit strategy Waseela-e-Haq has been started as one of the BISP initiative. This is a targeted scheme to provide loan
amounting upto Rs.300,000/- to the randomly selected beneficiary families currently receiving the cash transfers under BISP to be
validated through the programme eligibility criteria. The loan for “Waseela-e-Haq” can only be used for establishing mutually
identified businesses.
Proposed role in INSGB
It is proposed that Waseela-e-Haq program priorities should be set in line with the local market support needed to increase
availability of diverse food sources. Utility stores with diverse food at affordable rate could be one of the proposed priorities for
Waseela-e-Haq. Other business options include initial seed funding for establishing backyard poultry hatchery, purchase of livestock
for increasing household income as well as supply diverse food in the market. Such loans should also be available for buying seeds
and other inputs for agriculture
Other potential contribution of BISP in GB
To increase economic opportunities for BISP nominees for poverty reduction such as encashment of food vouchers at BISP
beneficiary established utility stores
Share BISP data with other sectors to enable them to develop intersectoral intervention such as food vouchers to those
students who are members of BISP beneficiary data base
Established data bank of skilled workers and share it with other partners.
Pilot testing of vouchers for the purchase of items of particular needed by households in efforts to prevent malnutrition, e.g.
soap, micronutrient powders, particular non-perishable food commodities.
Inclusion of social protection in provincial disaster risk reduction strategy.
49
16.0.CROSS SECTOR THREE: NGO/CIVIL SOCIETY PRIVATE SECTOR IN INSGB
Evidence from the countries such as Bangladesh, Peru illustrate that NGOs/Civil society has played a critical role in advocacy, policy
dialogue, collecting evidence and creating innovative intervention models.
Civil society in the INSGB strategy refers to “an umbrella term for a range of non‐state and non‐market citizen organizations and
initiatives, networks and alliances operating in a broad spectrum of social, economic, and cultural fields. These include formal
institutions, non‐governmental organizations, trade unions, professional associations, philanthropies, academia, independent
pressure groups, think tanks, and traditional informal formations, such as faith‐based organization, seminaries, and neighborhood
associations.” Pakistan and particularly GB has a very vibrant civil society and private sector role. During Attabad crisis and other
natural disasters, CSOs and NGOs have played an important role in resource mobilization and service delivery. NGOs and CSO in
other provinces of Pakistan have shown their powerful presence through advocating and successfully legislating law for “breast
feeding protection and child nutrition ordinance." NGOs from academia have been actively involved in nutrition-related research and
surveys.
Following sections identify the cross-cutting role of civil society / private sector in intersectoral strategy of nutrition in GB.
Potential role of private sector in WASH:
Analysis of the strategic documents from WASH sector highlights tan active role of private sector in GB in providing access to
community based, sustainable models of safe water and sanitation. The strategy envisions further expanding the role of private
sector and local support organization in reaching out to un-reached i.e. in Diamer. Following are some of the specific
recommendations for collaboration and support expected from the private sector presented in the strategy papers:
Private sector should play an active role in social mobilization and awareness raising about importance of WASH and its links
with health and nutrition;
Private sector participation is anticipated in positively influencing community attitudes for use of flush latrine, low cost
approaches to treatment of water and provision of safe water facility;
Private sector with their experience in community development activities and presence in the community is better placed to
persuade the community to support WASH intervention through in kind contribution such as by providing unskilled workers,
50
playing oversight follow up monitoring and maintenance role in the post intervention phase of the water and sanitation
facilities;
Private sector with their insights and research skills will be able to replicate and scale up technology that has been
successfully used in private sector programs for WASH intervention
Role of private sector in women development
The INSGB strategy envisages private sectors and CSOs playing a critical role in empowerment of women and thereby enabling
them to make healthier choices easier choices for themselves and their families. Strategic documents from WDD state private sector
and civil-society organization, an important resource in alliance building for advocacy for women development. INSGB considers the
support of faith-based leaders’ essential in helping to dispel some of the myths around women’s health and care.
Private sector is anticipated to support in improving women’s social status through up scaling opportunities for education, skill
development and providing access to market for economic development activities and thus to enable women to increase their share
in the household income and decision making. Local support organizations and women's organizations have the local community
representation and hence can play a key role in mobilizing women, particularly in hard to reach areas. The strategy envisages private
sectors to establish local community based economic development activities, which link the locally manufactured goods into the
larger markets. In order to create an enabling environment for working women to enable them to exclusively breast feed for six month
and introduce proper complementary food, private sector will be encouraged to create women friendly workplace with child care
facilities for working mothers to breast feed their babies and have access to safe chiild care support activities. Such services can also
be used to impart education and awareness around child health and nutritional health.
Sector Three: Role of private sector in health intervention
GB already has a network of private providers who are working for bridging the gaps in promoting health and addressing gaps in
health service delivery. Among the key, non governmental players currently operating in GB include PPHI and AKHS, P.
PPHI initiated its operation in GB and Skardu in 2007 after signing its MoU. The three stakeholders for this intervention are the
Federal Government, the Provincial government and RSPs. Today. Annexure two gives the details of the facilities operated by PPHI.
PPHI’s main contribution has been in turning non functional basic-level health facilities into functional through infrastructure
development, HR development and comparative small-scale community mobilization activities.
51
Aga Khan Health Service Pakistan is another major player in GB in health service delivery including playing a very active role in
implementing a community-based model of health promotion, mostly in hard to reach communities. AKHS, P works collaboratively
with other AKDN and Governmental organization in social mobilization activities, operating a network of NGO managed health care
facilities which range from basic health care facilities to small hospitals
INS –GB considers a very important role for private sector in health. INS-GB has proposed several roles of private sector in
improving health and nutritional health of the population:
The strategy (INSGB) expects to have private sectors commit to delivery of integerated health service package in the uncovered
areas; it aims to persuade the private sector to undertake researches needed for policy advocacy and report on certain key indicators
related to nutrition in DHIS and the agreed indicators in the oversight committee so that a compiled district based health outcome
report can be generated.
It anticipates ensuring implementation of regulation to ensure private sector hospitals and private sector managed BHUs have strict
rules to discourage use and prescription of formula milk unless medically indicated.
The strategy relies heavily on private sector to ensure health and nutrition outcomes of the population through mandating
manufacturers, producers and suppliers of salt and fortified wheat for food fortification and supply of iodized salt.
Role of private sector in agriculture, livestock and fishery promotion
Strategic document such as PC1s of agriculture sector, fisheries highlight conceptualizing, developing and institutionalizing models of
public private partnership. Such models will impact upon increased production and commercialization of trout and fisheries, research
and promotion of women friendly farming, revival of fish hatcheries backyard poultry farming and market mobilization to enable
access to diverse food products at affordable rates. INSGB anticipates private sector’s role in research activities to enhance
production of fish feed, safe medicinal products to enhance milk and meat production. Other areas for promoting partnership with
private sector include research and development arounf new technologies, inputs, and farm practices that may result in efficiency
and increased produce. Efficient use of water for agriculture growth, provision of agricultural credit and role in improving extension
services are other areas to be targeted through public private partnership.
INSGB proposes establishing “food authority” for defining and implementing standards and procedures to regulate and monitor the
food business, food labelling, food additive etc. Technical expertise and research through mobilizing private sector would indeed be
most beneficial particularly to define strategies for implementing these standards in private business market.
52
Role of mass media to create wide spread awareness about importance of consuming a balanced and healthy diet along with
consuming only fortified food items in the market will be most needed.
Role of private sector in promoting nutrition from education sector
Private sector particularly Aga Khan Education Services plays a key role in promoting girls education through establishing and
managing a network of primary, secondary and higher secondary schools. INSGB envisions scaling up child friendly schools that
provides healthy and safe environment, action oriented nutrition promotion activities and screening of children. Another intervention
that has been suggested to attract girls students to school is introduction of food voucher which would be a community based
intervention and will probably need mobilization of community organizations for implementing the program of distributing food
vouchers conditional to funds being made available for this intervention. Academic organizations are also expected to play a key role
in collecting evidence to support link between various incentives and implementation model with nutritional outcomes.
Proposed actions for promoting public private partnership and support
INSGB has highlighted an extensive role for private sector in each sector and building bridges between different sectors. This is
however only possible if:
Concrete measures are taken to enhance private sector’s trust for entering into public private partnership intervention;
Business rules and terms of engagement are clearly defined which may require establishing a task force that formulates and
articulates policies and provides platform for dialogue and joint decision making
Public sector reorgranizes and reviews its mechanisms of monitoring and funds disbursement so that they can play steward’s
role in all such interventions in an objective and efficient manner with expectation and key performance indicators for regular
reporting.
Undertake a study to analyse existing public private partnership interventions to identify barriers and problems faced that
cause delays in the decision making process as well as the fund releasing mechanism are avoided.
53
ANNEXURES
54
Annexure 1: Key findings of NNS 2011
• Pakistan has the second highest number of severely wasted children, 43.7% children are stunted, 15% wasted and 31.5%
are underweight in the country.
• Iron deficiency anaemia and Vitamin A deficiency remain widespread across the country.
• When compared with NNS, 2001 over the decade there has not been much change in the nutritional status in Pakistan.
• Over the past 20 years, “there has been little change in the prevalence of malnutrition in the population, despite greater food
availability and an overall increase in caloric intake per capita”.
Key findings of NNS-GB 2011
• Prevalence of wasting in children: 8%, stunting : 45%
• High prevalence of stunting indicates that the problem is a long-term and chronic in nature and need urgent priority attention
• Majority of the seven districts (six out of seven districts) in GB have severe deficiency of wheat.
• In case of maize, three out of seven districts are extremely deficient; one district is deficient, another is one sufficient and one
district is surplus producer.
• GB annually import 200,000 metric tons of wheat from Punjab at the subsidized rate through Pakistan Agricultural Storage
Services Corporation (PASSCO) under the federal Ministry of Food Security and Research (MFSR).
• Women and children in the marginalized group are most vulnerable to malnutrition. The marginalized group consumes low
nutritional food with inadequate protein and vitamins and limited food intake.
• 20% mothers are malnourished (BMI<18.5), Anemia in non pregnant women is 23.3% and in non pregnant it is 33.6%
• Ferritin level in non pregnant women is highest in GB and ferretin level of 14.9% is lowest in GB compared to other regions40
• 87.5% salt samples found in the market is iodized, indicates gains in this programming area.
40 New NNS page 53
55
• Calcium levels in the serum of the mothers of index child indicate that 44.5% of women from Gilgit had Hypocalcaemia.
• Food security mostly affects small and poor farmers who dominate the agricultural workforce.
• 60.2% of the house-holds are food secure, and 39.8% were food insecure;
• 9.2% of households are food insecure without hunger, 21.5% are food insecure with moderate hunger and 8.9% are food
insecure with severe hunger
• Increasing food prices make access to food a challenge for farmers and population in poor class.
• The unemployment rate, inequitable production and distribution systems are other compounding factors that make small
farmers with low income, food insecure.
• 53% population live in the borderline group that consumes food with low nutrition value and does not have meat as part of
their daily food consumption.
• Only 28 % population falls in acceptable level of food consumption group and 2 percent in the poor groupn in the survey from
Gilgit had Hypocalcaemia.
• Access to piped water: 73% of the household has access to piped water, 4% has access to well water, 6% has access to
community tap and 17% rely on water from other sources.
• 93 % of families never treat water before drinking,
• Soap availability in household is 17% (lower than the national average 58% )
• Children currently reporting worm infestation is 12.1%41,
• Prevalence of stunting among children is higher (48.2%) in the case of illiterate mothers, while it is lower (22.4%) where the
mothers are educated up to ten grades or more.
41 Figure 6.33 NNS 2011
56
Annexure two
Nutrition Conceptual Framework
Social, economic
and political context
Lack of capital: financial, human, physical, social and
natural
Inadequate education
Income poverty:
employment, self-employment, dwelling,
assets, remittances,
pensions, transfers etc
Inadequate care for
Women and Children
Insufficient health
services & unhealthy
environment
Household food
insecurity
DiseaseInadequate dietary intake
Short-term consequences:
Mortality, morbidity, disability
Long-term consequences:
Adult size, intellectual ability, economic productivity,
reproductive performance,
metabolic and cardiovascular disease
Maternal and child undernutritionImmediatecauses
Basiccauses
Underlying causes
Pakistan Integrated Nutrition Strategy
Short Term
Medium
Term
Long Term
57
Annexure three
58
Annexure four
59
Annexure five
ToR of the Provincial inter-sectoral nutrition committee
Following is the ToR of the provincial intersectoral nutrition committee
a) Ensure that various departments are able to work in a coherent and coordinated manner;
b) Ensure the annual district based work plans have been produced in consultation with other sectoral partners;
c) Provide oversight during implementation to ensure that the province achieves its targeted objectives and activities;
d) Carry out arbitration and mediation role in case of any conflict and differences between various sectors
e) Ensure that an overarching, intersectoral MIS has been developed that reports key performance indicators by all sectors on a quarterly basis;
f) Provide support and approval for mid term and end term evaluation.
g) Provide policy guidance and support in case it is needed.
g) Perform any other functions assigned to the intersectoral nutrition committee by Chief or assistant chief secretary.
60
Annexure six: Result based framework
GB Multisectoral Nutrition Results Monitoring Framework
Primary Impact Indicators42 Baseline YR 3 Target (2018)
YR 5 Target (2020)
Frequency of Collection
Child stunting (H/A <2)43 45%% 35% 30% Semi-annually HMIS
Child wasting (W/H <-2)44 8% 4% 3% Semi-annually HMIS
Child severe acute malnutrition (W/H<-3) - Semi-annually HMIS
Iron deficiency anemia in children45 36.2%% 30% 25% NSS
Vitamin A deficiency in children46 71.% 60% 40% NSS
Zinc deficiency in children 33% 25% 15% NSS
Prevalence of low birth weight (<2.5 kg) or “smaller than usual” NA Annual HMIS plus surveillance site data
Pregnancy iron deficiency anemia47 33.6% 20% 10% Semi-annual HMIS & NSS
Vitamin A deficiency (in pregnant women)48 44% 25% 15% NSS
KEY AGRICULTURE/Livestock/Fisheries/FOOD SECTOR INDICATORS
Intermediate Outcome Indicators Baseline YR 3 Target (2018)
YR 5 Target (2020)
Frequency of Collection
% of households “food secure”49 60% 70% 85% NSS surveys
42 “Child” = Children under age 5. “Maternal” = Reproductive age women. 43 PINS and operational plan presentation – slide 2 44 PINS and operational plan presentation – slide 2 45 PINS and operational plan presentation – slide 3 46 NNS 2011 – Page 73 47 NNS 2011 revise version figure 5.10 48 NNS 2011- page 55 49 Source: NNS 2011
61
% of children consuming at least four of seven food groups on the previous day
45% 65% Annual monitoring and NSS
% of landless or small holder rural households reached in the past 6 months with assistance in garden production, small livestock or fisheries
- 40% 70% Annual monitoring via MoA management information system
% of commercial wheat flour-consuming households consuming fortified wheat flour
- 30% 50% Annual surveillance site data
% of commercial edible oil-consuming households consuming fortified edible oil
- 30% 70% Annual surveillance site data
% of households consuming iodized salt (min 15 ppm) 85% 90% 95% Annual surveillance site data
KEY EDUCATION AND WOMEN SECTOR INDICATORS % of schools including nutrition in school curricula at any level - 45% 95%% Annual DoE management
information system data
% of secondary schools offering life skills education and weekly iron tablets to adolescent girls
- 25% 60% Annual DoE management information system data
KEY WASH SECTOR INDICATORS
Intermediate Outcome Indicators Baseline YR 3 Target (2018)
YR 5 Target (2020)
Frequency of Collection
% of dwellings with piped or tubewell/boring water 73% (NNS
2011) 80% 90% Annual WASH sector MIS plus
NSS
% households using hygienic sanitation facilities 76% 85% 95% Annual WASH sector MIS plus NSS
% of households with soap available at the washing place (observation) 17% 55% 70% Annual WASH sector MIS plus NSS
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KEY SOCIAL PROTECTION SECTOR INDICATORS % of BISP beneficiaries with at least one female school age child who has at least one school age girl enrolled in school
- 40% 70%
HEALTH AND POPULATION INDICATORS
Intermediate Outcome Indicators Baseline YR 3 Target (2018)
YR 5 Target (2020)
Frequency of Collection
% of infants 0-6 months of age for whom breastfeeding was initiated
within 1 hour of birth50 61.8% 70% 80% Annual HMIS and NSS
% of infants aged 0-23 months of age who received exclusive
breastfeeding up to six months51 14.5% 40%% 70% Annual HMIS and NSS
% of children who were introduced to complementary food between
6-8 months of age52 51.3% 60% 70% Annual HMIS and NSS
% of mothers with a child aged 0-12 months who received any ANC
during their last pregnancy53 80% 85% 90% Annual HMIS and NSS
% of children aged 12-60 months who received a vitamin A supplement in the past 6 months
- 80% 90% Annual HMIS and NSS
% of children aged 6-24 months who consumed multimicronutrient powder within the past week
- 30% 40% Annual HMIS and NSS
% of children aged 6-60 months with diarrhea in the past two weeks who received ORS with zinc
- 50% 60% Annual HMIS and NSS
% of communities in pre-determined food insecure districts with functioning CMAM
- - Annual HMIS and NSS
% of unions covered by LHWs, CMWs, NGOs or CSOs - - Annual HMIS and NSS
50 NNS 2011- PAGE 84 51 NNS 2011 PAGE 85 52 NNS 2011 Fig. 7.5 53 in I n t e r - S e c t o r a l C o n s e n s u s B u i l d i n g O n Nutrition Strategic/Operational Planning, October 3-4, 2012, Serena Hotel Gilgit page 11 ‘
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Annexure seven
SECTOR 1: HEALTH AND POPULATION WELFARE
BACKGROUND AND RATIONALE:
1. Overall nutritional status of GB is significantly better than rest of the country. It is lowest in wasting (8%), and in stunting (45%); it
is better than other provinces except AJK & Punjab. In pregnant women, iron-deficiency anemia (IDA) is highest (30.4) but in non-
pregnant women, IDA (10%) is lowest in GB when compared with all the provinces of Pakistan. In order to sustain its
achievement and improve poor health indicators, the province needs urgent measures to address nutrition problems and issues.
Nutrition policy that advocates inter-sectoral actions is vital for creating an enabling environment for policy and program options to
be enacted to address the problem directly (e.g. food subsidies to the poor) and/or indirectly (e.g. income generation or job
creation). Absence of a clear nutrition policy is stated to be an important reason for lack of enough focus on malnutrition in a
country.
2. Health strategy background document indicates that there are many overlaps and fragmentation in various departments of health
sectors such as MNCH, LHWs, EPI and Nutrition. These departments have developed their own HMIS that has much duplication
and does not support in decision making. Lack of effective communication and coordination among these departments, have
compromised the opportunity for building on synergies and also pose a major barrier in providing continuity of care. Mapping of
different departmental role, activities and development of integrated outcome indicators would be most essential for reducing
fragmentation in health service delivery.
3. in 2002, Pakistan introduced the “Protection of Breast-Feeding and Child Nutrition Ordinance." The Ordinance in Chapter III
Under (2) states that "No person shall in any manner assert that any designated product is a substitute for mother's milk, or that it
is equivalent to or comparable with or superior to mother's milk. "Protection of Breast-Feeding and Child Nutrition Ordinance
2002” also stress upon formation of a National Board/forum to monitor the implementation of the said Ordinance.
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Right after the devolution, three provinces, Punjab, Sindh and Balochistan have also introduced legislation on breastfeeding and
child nutrition in line with the “Protection of Breast-Feeding and Child Nutrition Ordinance 2002”. GilgitBaltistan has not yet
introduced the legislation. As a result, it was shared during stakeholder discussion that many public and private sector hospitals
and care provider prescribe formula milk to babies which harms the health of the baby.
4. Current curriculum of physicians has minimal information on IYCF and nutrition. On the other hand, curriculum of nurses and
paramedical staff has comparatively more information to enable them to render counselling on benefits of balanced diet,
importance of maternal nutrition and impact of malnutrition on the early childhood period. With the inclusion of IMCI in the medical
college curriculum, emphasis on breast-feeding and child nutrition has considerably increased, but it still does not cover some
important areas such as management of breast feeding problems, exclusive breast-feeding and other aspects of infant and child
nutrition. Discussion and content lack any emphasis on CMAM and stabilization protocols to be used in stabilization center.
Similarly, curriculum lacks any discussion on links between nutrition sensitive and nutrition specific interventions in the curriculum
to enable health care providers to appreciate the value of inter-sectoral collaboration in addressing the issue of malnutrition.
5. In order to strengthen curriculum of other sectors in nutrition sensitive interventions, it is essential to mobilize outreach workers
from these sectors to disseminate and re-enforce key messages around nutrition, customized according to their own setting.
Presently, non health sector such as agriculture and education are not mobilized enough to reinforce and strengthen the
dissemination of health messages from different platforms. This is a missed opportunities because agriculture/livestock/fisheries,
WASH, Education and LGRD has a large force of outreach workers who work in the rural and distant communities and potentially
have opportunities to influence rural population and farmer’s behavior around any topic including nutrition of adolescent girls,
expectant women and children. DoH can provide technical support and assistance to other sectors and can seek input to
strengthen its own focus on multi-sectoral nutrition approach.
65
6. LHW/PHC program has a central role in changing the household behaviours around nutrition. Unfortunately, LHW program has
faced severe financial and budgetary constraints which have affected its role tremendously. Refresher training on LHWs Manual
and MIS tools to LHWs was a routine part of Program activity since its inception but due to Lack of funds these routine activities
have not been conducted for the last four year. Effective implementation of information system has also been compromised due
to resource constraints inspite of the fact that LHW MIS is literally one of the most powerful systems currently in place if
implemented accordance to the standards. Logistic Supply system has also been compromised as a result LHWs do not have
access to necessary supply and medicines. Finally, effective implementation of the LHW program will ensure the reliability of data
and information and monitoring and supervision. Unfortunately, out of order vehicles and unavailability of vehicles is another
major challenge in carrying out monitoring supervision activity.
7. Currently, Education sector has “Child-Friendly Friendly School” concept instituted that requires annual health screening of
children and parental awareness programs as well as de-worming. Up scaling of the CFS model will require close collaboration
with LHW-PHC program. Meanwhile, there is no formal MoU agreed between Health sector and Education sector to carry out
this activity. Having such an arrangement will enable LHWs to achieve their own targeted objectives more efficiently.
8. Another important area that needs attention relates to availability of fortified wheat, edible oil and salt. Current absence of
legislation for wheat fortification does not mandate wheat millers to fortify their flour. Wheat is the main staple diet of the
population. Cost of the iron mix is not very high but in the absence of any demand from the informed buyers, the manufacturers
do not feel obligated to produce flour. While intersectoral action would be central to introducing these interventions, it is important
to ensure that their one central department i.e. food department that is able to mobilize range of stakeholders to lobby for
enforcement of legislation in the province.
9. Vitamin A deficiency implies is a lack of vitamin A in humans. It is common in developing countries but rarely seen in developed
countries. It is present in green leafy vegetables and fruits. Micro-nutrient initiative and UNICEF are supporting Vitamin-A
supplementation on Polio NIDS for children of 06 to 59 months. However, in the current HMIS, there is no indicator that could
66
inform Vitamin A coverage. Micro nutrient initiative has also committed resources for the assessment of the national Vitamin-A
coverage survey for the years 2011 and 2012 which before devolution was planned to be conducted under the rubric of Nutrition
Wing, of previous Federal Ministry of Health. However, under the devolved set up it will now be taken under this plan through
operational research. Once the NIDs come to an end, alternate models for delivering vitamin-A after the NIDs need to be tested
out.
10. Inter-sectoral intervention on nutrition is first such initiative for GB and the rest of the country. Topography of GB is different from
other parts of Pakistan. Therefore, it is imperative for the region to carry out operational researches, which are context specific
and enables GB to pilot and scale up its initiative.
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SECTOR 2. BACKGROUND AND RATIONALE FOR AGRICULTURE/LIVESTOCK/FISHERIES
INTERVENTION
1. Current food insecurity in GB has several reasons but poverty and lack of assets in marginalized poor population are the key
reasons. Agriculture systems have a critical role in the provision of food, livelihoods, and income. Women in most of the rural
areas play a very crucial role in the agriculture production. Hence, policies that support their empowerment through skill
development as well as investment in pro-women credit schemes and women friendly agricultural machinery would be most
needed.
2. Poor and small landowners, including women landowners who are very few have fragmented land holdings, do not produce
enough crop for the sustenance of their entire family through-out the year. Fragile topography to natural calamities and food
prices has further contributed to malnutrition by playing a critical role in compounding the prevalence of malnutrition. The
three pillars mentioned above can only be addressed through a provincial agriculture/livestock/fisheries and food security
policy that is pro-poor and pro women.
3. Lack of measures to ensure “food safety” is another reason for malnutrition caused by consuming harmful effect of poor
quality diet. Food safety implies that food available for consumption at public and retail store is safe for human health. Food-
borne illnesses take a huge toll on the productivity of the affected individuals and populations. Diarrhea, Typhoid and other
more serious diseases can be life threatening particularly when it affects children. Low quality of edible oils and other food
products, crops sprayed with harmful pesticide and use of chemical fertilizer and sale of poor quality of wheat, etc. may have
injurious effects on health but in the absence of enforcement of any law, these are freely available in the market.
4. There is no check or control on the import of pesticide available in the market. These pesticides are known to have serious
environmental and health implications for man and other life forms if their use is not contained beyond certain limits. If not
used at the correct time and accurate amount, i.e. during the period when crops and other plants are blooming, it could
impact upon the bees much needed for cross pollination.While, state has a major role to play through enforcing a legislative
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framework54 for food safety, civil society and consumer also have a critical role to play. Pakistan has a set of laws, which
deals with various aspects of food safety. These laws include Pakistan Pure Food Laws of 1963, Pakistan’s Hotels and
Restaurant Act of 1976, The Pakistan Standards and Quality Control Authority, 1996. These laws, if enacted and enforced
will have tremendous capacity to achieve an at least minimum level of food safety. Details of these laws are attached as
annexure one
5. Currently, the medicines being used by the veterinarian for treatment or enhancing the production of milk and meat
production are being approved at the federal level but at the implementation level, concerns were raised in a similar exercise
in another province indicating that the lack of monitoring of the quality of medicines and other inputs available and used for
increasing the meat and milk production has huge implications for human health;
6. Agriculture and livestock departments and its sub sectors have quite a large force of extension workers. Rapidly changing
environmental and ecological conditions, investment in research and development as well as access to information
technologies requires means to keep extension workers also updated with the new knowledge. In turn, the extension workers
must have the ability to transfer this information to the beneficiaries. This will enable them to keep beneficiaries (farmers)
updated with changing approaches and emerging technology with its positive impact on agricultural development and out puts
leading to agricultural growth and poverty reduction.
7. Malnutrition is more common in rural areas of Gilgit-Baltistan. In addition, rapidly changing ecological situation and
globalization requires agriculture and live stock sector to keep pace with new knowledge being generated globally in the area
of agriculture through integrating it in the curriculum of the extension workers and DoA, Fisheries and Department of
Livestock (DLS) . DoA and DLS, livestock and fisheries are already cognizant of these challenges and are adopting
measures to improve the outcomes.
54MazharSiraj. “Food Safety Legislation in Pakistan: Identifying Entry Points for Public Intervention”. Research Fellow CRCP
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8. Majority of the farmers in the hilly and mountain areas of GB are small land-holding families, cultivate less than one hectare of
land each. Unfortunately, as a result of declining soil fertility, the quality of the produce is also deteriorating. Such challenges
have the potential to contribute to the chain reaction process of poverty–resource degradation–scarcity–poverty55.
9. Small farmers also lack facilities to reduce the post harvesting loss primarily resulting from small and scattered volumes of a
highly uneconomical scale; poor knowledge on harvest maturity and harvest timings; poor harvesting and field handling
practices; poor packing, transportation and storage; lack of physical infrastructure, including access roads and market places
and lack of proper value addition.
10. Literacy level of women in GB is considerably better than in other provinces of the country. Many women are also active in
small and home based income generation activities therefore, there are less challenges to mobilizing women and equipping
them with up to date knowledge and skills in good farming, food processing, kitchen gardening, apiculture (bee keeping), and
other such activities that on one hand increases income and on the other hand, can contribute to providing diverse sources of
nutrition to the population.
11. Fish feed plays a very important role in improving fish breed and enriching its nutrient value. With increasing demands,
investment in aquaculture and community based or backyard fish farming would become an important means of poverty
alleviation. Fish feed play a very vital role in promoting nutritional value and protein content of the fish meat. Unfortunately,
there is not enough information available about the type of fish feed that would be beneficial. The choice of fish feed in GB is
limited and expensive because of the additional cost incurred in bringing these seeds from down country as a consequence
absence of availability of a local market. Farmers on the basis of trial and error use various cheap, local variety of fish food.
Sometimes, poor quality of fish feed may put entire produce of fish farm at risk. Feed is the highest proportion of operational
costs and, therefore, the profitability of the operation depends largely on the performance of a feed.
55Jodha, N.S.;Shrestha, S., 1993. Sustainable and more productive mountain agriculture: problems and prospects. In Mountain Environment and Development –Part 3 (Thematic Papers),pp 1-65.
Kathmandu: ICIMOD.
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12. Situation analysis suggests that at present poor segment of the population has very limited access to capital and finances for
such home based facility to produce and rear livestock. Several scientific literature reviews of homestead food production
systems have been done in the past decade56, 57, 58. These reviews focused on different types of programmes and nutritional
outcomes. One consistent message from these studies is that nutritional effect is more likely when
agriculture/livestock/fisheries interventions target women and include women’s empowerment activities, such as improvement
in their knowledge and skills through behavior-change communications or promotion of their increased control over income
from the sale of targeted commodities
13. High level of food insecurity and malnutrition across the country warrants creation of alternative source of food and protein
such as aquaculture and livestock with potential to provide a good source of protein and other nutrients to the population.
Lack of awareness about benefits of these produce has resulted in poor demand which poses a barrier for investors who
might be keen to invest in this business. Social marketing approaches have been successful in creating demand for various
health behaviours such as birth spacing, vaccination, as well as for introducing foods like Kentucky Fried Chicken, McDonalds
and Pizzas etc. Instituting social marketing and awareness strategies for consuming fish, milk and meat diet and products will
result in increased demand which in turn will incentivise tradition fish farmers and livestock producers to produce and market
more of these healthy foods at affordable rates. Similarly, various platform such as education, agriculture and health will
disseminate messages around eating good quality yet affordable and within their means through improved cooking practices.
14. Although intake of balanced diet is vital for health and prevention of disease, food fortification is recognized as a highly cost-
effective way to improve the micronutrient intake of populations. Such an intervention however, requires close regulatory
monitoring by which the private and public sector collaborate to produce quality fortified food. Legislation for universal salt
iodization has been implemented in GB which is evident from the NNS 2011 report that most of the salt available in the
56World Bank. From agriculture to nutrition.Pathways, synergies and outcomes. Washington, DC: The International Bank for Reconstruction and Development, World Bank, 2007. 57Leroy JL, Ruel M, Verhofstadt E, Olney D. The micronutrient impact of multisectoral programs focusing on nutrition: examples from conditional cash transfer, microcredit with education, and agricultural programs. http://www.micronutrientforum.org/innocenti/Leroy-et-al-MNF-Indirect-Selected-Review_FINAL.pdf (accessed May 16, 2013). 58Arimond M, Hawkes C, Ruel MT, et al. Agricultural interventions and nutrition outcomes: lessons from the past and new evidence. In: Thompson B, Amoroso L, eds. Combating micronutrient deficiencies: food-based approaches. Rome: CAB International,Food and Agriculture Organization, 2011: 41–75.
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market is iodized; much is however left to desire for ensuring availability of fortified wheat and edible oil to the population.
One of the key reasons for this phenomenon is lack of supply for such a product which in itself is dependent upon poor
demand from the population because of lack of awareness. As a result manufacturers do not see much market for slightly
expensive but better quality product in as they have to GB.
15. In order to enable GB to exploit the potential of market through provision of off season vegetables, farmers will need to have
access to good quality and continuous supply of safe seed. In order to provide access to the farmers with improved varieties
and reliable access to quality seeds for produce which is more appropriate for GB climate, GB agriculture department has
planned in its PC1 to develop its own capacity in the production of quality and safe seeds. It is however important to
recognise the success can only be achieved if the production of seed is sustainable, if the seed supply system is within easy
reach of the population and if the training of the farmers and seed grower ensures emphasis on quality seed production.
16. The Department of Agriculture, livestock and fisheries needs urgent support through research and development activities for
increased local production of seeds, fertilizers and safe inputs for increasing meat and milk production. In the absence of
these supports, farmers and cattle grower are dependent on using whatever quality of these inputs available in the market. In
the agricultural sector, seeds and plant varieties/species need to be evaluated and updated with more value additions, on
production and post-harvest practices, and above all the capacity of the farmers and the Department of Agriculture. Already
some research & development support is available to the Department of Agriculture/livestock/fisheries with developmental
partners support, it is essential to upscale the current capacity and broaden the scope to include other subsectors of
Agriculture.
17. PPP offers an alternative approach to instituting projects that are traditionally financed and operated by the public sector. One
of the most appealing aspects of PPP is sharing of risks related to the projects between the partners. When well structured,
PPP helps addressing specific costs and investment challenges, creates improvements in efficiency i.e. improved service
qualities (expertise, new technologies, a potential to attract and retain better performing staff) and low cost management.
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18. Partnership can be of different types: Financing by private sector is one approach whereby private partnerships allow faster
and efficient construction of big-scale projects, which might otherwise require longer time for approval for financing. One of
the opportunities is in the areas of commercial fish farming where partnership with private sector may result in increased profit
margin and better sustainability. The private investor in a PPP project is bound to be extra diligent when assessing its longer-
term risks for financing, construction, quality of service, and maintenance.
19. The sector has various departments working independently to produce sustainable results and promote change. Intra-
sectoral coordination forum will allow dedicated teams to undertake relevant tasks carried out by trained staff in that area of
work while also ensure a strong monitoring mechanism.
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SECTOR 3: WATER AND SANITATION SECTOR
Background and rationale
1. National Sanitation Policy and National Drinking Water Policy have been approved in 2006 and 2009 respectively with the
objective to improve water and sanitation coverage and quality59. Aim of the policy is to provide safe drinking water to the
entire Pakistani population by 2025, including the poor and vulnerable, at an affordable cost. Main objective of these policies
is a clearer separation between the functions of service provision and regulation. Since devolution, it has become imperative
that the provincial policies and strategies are approved.
2. Provincial water supply strategy has also been developed. It is envisaged that after enforcement, the policy will have a huge
potential to provide sustainable system drinking water to the entire population of GB by 2015, for improving quality of life and
reducing death due to water borne disease. The focus of the strategy is on adequate supply of water, affordability and
equitable and sustainable distribution system of water.
3. The provincial sanitation strategy has also been developed and awaiting approval. The strategy aims to provide adequate
coverage of safe sanitation by the year 2015 and aims to provide an open defecation free environment by the year 2015 to
meet the requirement of MDG.
4. MDG seven “to ensure environmental sustainability” and target 10 is “to halve the proportion of people without access to safe
drinking water and sanitation by 2015” cannot be achieved without actions to promote gender equality and women’s
empowerment. Women and young girls are most affected in the absence of access to water and sanitation close to their
homes or in their homes. According to one estimate, women and girls in low-income countries spend 40 billion hours every
year fetching and carrying water from sources, which are often far away and may not, after all, provide clean water60. One of
the reasons why women remain marginalized and are not involved in these discussions, example in Indonesia and Malawi, is
because of pre-judices about their lack of ability to participate in the technical discussion. Their participation in such an
infrastructure-related project is viewed as stepping out of their traditional role although, in reality, women are the primary
59 a b c Government of Pakistan. Ministry of Environment (September 2009). National Drinking Water Policy. Draft. Retrieved 2010-03-07 60 Ibid
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users of water, and hence are the most qualified to comment on n appropriate design for a water system when given an
opportunity as noted in these countries. Similarly, they are the most powerful actor for ensuring the follow-up maintenance of
these schemes such as repair of tube wells or maintenance of the sanitation system because it increases their workload.
5. In spite of availability of technical support and systems, delivery of safe water and sanitation service is many times
compromised. One of the reasons for this state of affairs is lack of competency of the staff operating and managing the water-
supply system or maintenance of sanitation services. There could be several reasons for this but lack of required training in
managing a proper and context-specific system is of crucial importance. This in turn would require incorporating these
messages in the curriculum of the staff responsible for such services. Concurrently, a system of monitoring is very vital for
ensuring that the water being supplied meets the required standards of provision of the good quality of water.
6. Nutrition affects multiple sectors but unfortunately, there is no coherence and uniformity in the communication messages
linking the role of the sector in improving nutrition. In GB, reason for people to desire better sanitation facility is for gaining
status and of practical reasons such as greater privacy, convenience and comfort especially for women. Public awareness
about safe drinking water, good sanitation is also lacking. As a result, open defecation practices are widely practiced.
7. For any behaviour change communication strategy to sustain, re-enforcement of the health awareness messages from
multiple platforms will bring about a sustainable behaviour change. Each of these sectors offers a platform that can be
mobilized for community awareness purpose. in its “Provincial behavior change communication strategy (BCC strategy)61”,
GB has committed to create awareness amongst every citizen through various means of communication to adopt safe
sanitation, healthy environment, healthy living measures, use of clean drinking water and use of improved personal hygiene.
8. The BCC intervention for GB should also promote good practices and innovations such as those launched by BACIP (Aga
Khan Planning and Building Services) i.e. efficient use of fuel leading to low cost approaches to boiling water which is much
needed for maintaining good personal hygiene in severe cold weather before cooking and after defecation, use of soap for
washing. More awareness also need to be created about how water can get contaminated even after collection from a safe
source.
61Planning and Development Department, GB. (2011). Behaviour Change communication (BCC) strategy
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9. Most of the infrastructure projects for water and sanitation require follow up maintenance of the project. In the absence of
availability of such a support, delivery mechanism, safe water and sanitation service is compromised. Communities in GB are
very well organized and are quite able to play their role effectively. AKRSP has applied this model and lessons can be learnt
from their experience.
10. Access to safe drinking water and proper and functional system for disposal of waste is vital for reducing diarrhea and other
water borne illnesses amongst children and adults. District Diamer has the lowest coverage of piped water of only 34% as
against 91% for Hunza-Nagar. In addition to that Diamer district has the highest percentage of non functional system (11%).
Inspite of the fact that heavy investment in this sector has been made in the past, it is unfortunate that only 58% of these
schemes are functional. Considerable investment has been made by the Government and various NGOs to provide drinking
water to the population. About 849 drinking water supply schemes have so far been constructed by various Government
department and NGOs. 74% of the villages have been provided with pipe water but due to low quality of construction and non
existence of a full proof mechanism, under which the beneficiaries are bounded to operate and maintain in a sustainable
manner, only 60% are functional, 21% are semi functional and 19% are non functional. Similarly, while water schemes have
been instituted with very high budget, its utility and maintenance does not exist in those rural areas. Sanitation system varies
from area to area with open defecation common in all the province and flush latrines limited to those where families can either
afford it or are aware of its importance.
11. GB has extensive experience of working with private sector such as AKRSP, WASEP etc. “Feasibility study of environmental
integrated water and sanitation and hygiene practices” refers to the technology used by WASEP as being better. AKRS, P’s
model of community participation has instilled a sense of ownership in the community. It is very important to unravel the
underlying models of this technology and disseminate it as well as incorporate the learning in the new intervention. In
addition, there is now technology invasion in the cultural mileu of GB which pose a challenge in institutionalizing these
initiatives.
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SECTOR 4: EDUCATION SECTOR
BACKGROUND AND RATIONALE
1. GB has already invested considerably in girl child education. The gross enrolment rate is 75% and more than two-thirds (67%) of
girls now attend primary school as opposed to only 29% in 1994. The gender parity index (ratio of girls to boys) of 0.73 for
primary school is in line with the national figure, though still low by international standards62. The region can only achieve its
desired economic development outcomes and prosperity if upward trend in education is maintained and priority is given to
education in general and girls’ education in particular. Studies63 have shown impact of education on reducing in-equality,
improving economic growth and labor skills, increased opportunities for well paid employment. In addition, the study argues that if
girls are deprived of education, there will be a negative impact on economic growth.
2. The strategy has aims to address some of the barriers in achieving gender equity through focusing on policies that incentivizes
families on one hand and improves nutritional status on the other. It aims to mobilize communities with messages around
importance of girls’ initial enrolment, attendance and continuation of education between levels but to put in place incentives for
enrolment of girls students at primary level. The paper envisages training of teachers to make their behaviour more gender
sensitive. Likewise, the curriculum will be reviewed to make it gender sensitive.
3. According to WHO, anaemia is highly prevalent globally in school-age children than in pre-school children, although data is
limited64. In poor areas, children often come to school without a good and balanced breakfast. The experiences from other
developing countries65 indicate the benefit of offering mid day meal on nutrition outcomes. For example, Food-for-school
programmes, such as ‘take home’ food to children with high attendance records in India, have shown increased enrolment and
attendance, particularly for girls. In Indonesia, the new school feeding program was implemented but first in ‘poor’ villages and is
62Gilgit-Baltistan education strategy, 2013–2025 63Sattar.T. et al. “ Socio-Political and Economic Barriers of Development in Education Sector of Southern Punjab (Pakistan). 64Nutrition of the Scholl-Aged Child: www.unsystem.org/scn/archives/scnnews16/ch03.htm 65State Statistical Office of Mongolia.Mongolian economy and society in 1996.Uaanbaatar, 1997.
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still in its early days. Experience from Kenya66 indicates that it is essential that once started, the program receives political
commitment for long term funding support even during economic crises. In Pakistan and other countries, vitamin and mineral
fortification of biscuits have shown significant improvement of micronutrient status when given as a snack to school
children.Lesson from Kenya highlights the key role of parents in sustaining school feeding programm, in assuring safety and
quality of food from vendors and hawkers, and the problems of money given to children for food being spent on drugs. In light of
these experiences, it is recommended that every child should receive one glass of milk with fresh fruits from all schools but
particularly to children from school in the areas where high prevalence of mal-nutrition is reported. During education stakeholders
meeting in GB, it was shared that in GB, it is a norm is for a child to bring a piece of chappati or bread with them to school. Mid
day food program has vast potential not only to improve nutritional status of the children but in GB context where some areas are
very poor, it can attract school children to schools and thereby improve the school performance. Stakeholders during discussion
expressed their concern about long term sustainability of such donor funded projects and strongly suggested that any feeding
program would only be accepted if it is funded through regular budget i.e. ADP instead of donor funding; in addition, it should
have strong commitment for continuing even during difficult economic times.
4. Hand washing has a very critical role in maintaining health and hygiene and preventing illness. Schools provide ideal platform for
instituting such healthy habits. In addition, lack of good water and sanitation facilities is a disincentive for girls’ enrolment into
schools as they have to travel on foot long distances which is very challenging when there is absence of a proper sanitation
facility in school. Department of Education has already achieved quite a significant success in ensuring water and sanitation
facilities from almost 80% of the schools. Fortunately, since DoE has its own engineering department, it has the capacity for
maintenance of such schemes. Strengthening of school management committee’s role in monitoring of these schemes is vital for
long term functional sustainability and approaching authority in timely manner particularly because the weather also has the
tendency to affect these schemes.
66Oniang’O., R, A. school feedsingprogrammes: lessons from Kenya
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5. Child friendly school (CFS) is a successful intervention in GB. This began with 40 schools in Gilgit district and has expanded to
now included 260 schools in Gilgit, Hunza- Nagar and Skardu district. Child friendly school67 in GB is built on the model of WHO
“health promoting school” based on the following key components: parent-teacher school health committee, mothers support
groups, healthy school environment, school health components in the curriculum, annual school health checkup of children and
also of teachers, school canteen or feeding program and field based activities and actions. CFS aims to provide an enabling
environment for children to achieve highest potential for performance in their education and this is not possible if the child is
physically and nutritionally healthy. CFS schools have maximum potential to provide opportunity to DoE to incorporate
components around nutrition, determinants of nutrition, food and skill based activities around kitchen gardening etc. DoE will
coordinate with health sector/LHW program in the catchment area of the school to undertake the health awareness activity for
school community, de-worming of children and school health screening.LHWs will use WHO road to health chart for school
children and will refer the sick children identified for further treatment to the next level care facility. Health sector will establish
links across different level of health facility so that children identified with a problem is referred and the family is counseled for
seeking care and adopting corrective measure at home.
6. In order to improve the nutritional status of children, teacher’s skills will need to be developed in the area of skilled based nutrition
education and identification and prevention of malnutrition. PDCN is currently a resource for CFS and its capacity could be
upscaled further to include establishment of a skill lab to enable teachers to transfer the critical learning about consumption of
healthy food to their student and nutrient values of different food products. The teacher’s curriculum should include ideas for
activity oriented learning approaches on nutrition such as organizing various community nutrition projects and activities. Most of
the targeted schools if identifies community planting areas, they could teach the art of growing school vegetable garden. PDCN’s
expertise could be exploited to enable it to serve as a resource for the training of the educators working from other sectors such
as health, agriculture/livestock/fisheries etc. PDCN can also play a key role in building capacity of SMC and MSG in sensitizing
the important change agents for consuming healthy diets.
67Khan, A.S., Mir, K., Parveen, M,.andTaj, Z. (2012) “A jouney from a haunted school to a child friendly school in GilgitBaltistan under UNICEF child friendly schools project: a case study99
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7. Parents can play a very powerful role in influencing child’s nutritional habits. Parental education is therefore essential for
improving nutritional outcome. On one hand, educated parents have opportunities for earning more household income and
thereby procuring adequate and good quality food for the family. On the other hand, educated mothers are more informed about
what to eat and how to select a healthy combination of food. Mothers support groups established in school have the potential to
play a very important role in improving the cleanliness of school environment and giving awareness to mothers regarding physical
cleanliness of children, and reducing absenteeism rate.
8. GB has huge potential for developing innovative approaches in the area of education such child friendly schools. Education
sector with AKES support is also in the process of reviewing agriculture curriculum and testing models for inducting girls into
school. It is also implementing several activities in close collaboration with private sector but these activities need to be properly
evaluated by a third party to ensure that that programs are effective enough for scaling up.
9. Severe death for documenting operational effectiveness is being felt particularly for policy and planning. One of the reasons for
this dearth is lack of enough resources to allocate to such activities. INSGB provides an excellent opportunity to education sector
to address this gap.
10. Education strategy paper for GB has outlined their resolve to review their district education information system. This is a unique
opportunity to incorporate few nutrition sensitive indicators in the sectoral strategy. The proxy indicators in the MIS such as
around school attendance rate, school performance rate, boys versus girls school admission rate, # of children that received
deworming tablets and # of children that received annual health screening etc.